Clinical Documentation Integrity: 3 Best Practices

Clinical documentation integrity (CDI) is the process of ensuring that a medical record is accurate and thorough. It starts when a patient presents to a healthcare setting and continues through the revenue cycle. High-quality CDI translates what’s happening at the bedside (or other care environment) into a robust clinical story that serves the patient, providers, and payers.

Though the value of high-integrity documentation is clear, it can be challenging to protect processes that generate it — especially given the rapid integration of new technology into documentation workflows. While tech-assisted documentation practices and automated “nudges” have helped providers gain back time, they also create legal and operational risks. The Office of Inspector General identified some EHR features (such as an ability to copy/paste notes and the availability of templates) as risks for fraud, abuse, and misaligned payments.

This guide provides a closer look at the CDI process in healthcare and the ways facility leaders can support it. We’ll discuss methods that help care providers interface with technology to capture clinically accurate stories for reporting, compliance, and reimbursement purposes. We’ll also cover three best practices for promoting high-integrity documentation on your clinical team.

What Is Clinical Documentation Integrity?

Clinical documentation integrity, also called clinical documentation improvement, is the process of telling a clinical story that accurately reflects the patient’s condition and the care provided. Members of the multidisciplinary team contribute to the creation of an accurate medical record for a patient. The record:

• Keeps all members of the team up-to-date.
• Informs subsequent care.
• Lets payers know what happened so that they can assign an appropriate reimbursement rate.

Effective CDI Process: 5 Steps

Creating high-integrity documentation is a process, not a one-time event. Documentation is revised and refined as it filters through the revenue cycle. The revision process must meet ethical and legal standards. Here’s a breakdown of the steps.

1. Documentation of Bedside Care

Clinicians interact with a patient, provide care, and document their findings and actions. The documentation reflects what the clinician knows at the moment about the patient. This is typically done within an EHR system.

Example: Within two hours of presenting to the ER, a patient’s medical record contains an RN’s assessment, initial vital signs, lab values, ER physician note, and an ECG reading.

2. Clinical Audit or Clinical Documentation Improvement Specialist (CDIS) Review

A specialist, such as a clinical documentation integrity nurse or clinical nurse auditor, checks documentation to look for gaps and inconsistencies. Software can also be used to identify weaknesses. If issues are identified, a query is sent to address the concern and seek clarification.

Example: A CDI nurse audits a patient chart and sees a high WBC lab value documented at 6 a.m., and a fever and tachycardia documented at 8 a.m. The RN note at 9 a.m. states that the patient’s surgical incision “looks pink” but there is no further wound assessment data recorded. The CDIS sends a query flagging the gap and requesting additional documentation.

3. Clinician Revisions

The care provider follows professional, ethical, and legal standards to address the query by making the documentation more complete and accurate if possible. Records are not erased, but rather fleshed out or amended. EHR systems often include features that keep a record of all changes made, along with timestamps.

Example: An RN adds a “late entry” clinical note that describes the time and date of a wound assessment, her subjective and objective assessment findings at that time, and the reason for the late entry.

4. Medical Coding and Queries

Medical coding specialists translate clinical documentation into billing codes. If a question comes up regarding a code, they’re not permitted to guess, make decisions about whether a diagnosis is present, or interpret clinical findings. Instead, they must query the clinical team for clarification.

Example: A medical coder is unsure whether a patient’s condition should be coded as adult failure to thrive or sarcopenia. He queries the healthcare team to get more information.

5. Additional Clinician Revisions

The healthcare clinician addresses queries to make documentation more accurate and complete. The query-driven revisions are typically recorded within the EHR, which ensures updates are transparent and compliant.

Example: A nurse practitioner involved in a hospice patient’s care makes her documentation more robust by writing an addendum to her assessment findings. She writes: “At 14:00 on 4/24/25 the patient had a flat affect, did not look up to greet me, and refused to get out of bed. She stated that she had not eaten in two days because she felt depressed.”

Additional Feedback From Payers

If the above steps are not completed (or completed poorly), the result could be low-integrity documentation that triggers additional feedback in the post-service phase of the revenue cycle. A payer might deny a claim, request more information, or provide improper reimbursement.

For example, an insurance company could issue a clinical validation denial, rejecting the claim on the basis of not enough clinical documentation to support the diagnosis. Even when documentation is very strong, claims can be denied related to validation concerns — an issue that many facilities contend with. Proactively generating strong documentation doesn’t solve the problem of denied claims entirely, but it’s one way to decrease the number of preventable denials.

Indicators of Suboptimal CDI

Vague, incomplete, or inaccurate documentation can create problems for patients and facilities. Here are some red flags that could indicate that documentation workflows need improvement.

• Mismatched or concerning quality metrics, such as high patient mortality rates alongside low severity of illness scores, or high observed-to-expected (O/E) mortality ratios
• Low-detail charting for complex patients
• High rates of retrospective queries (i.e., after the patient has been discharged)
• High volume of late entries by providers
• Staff voices concern about inability to chart in real-time
• High rates of claims denials

3 Best Practices for Clinical Documentation Integrity in Healthcare

Documentation practices have always been important to the delivery of care. The current influx of technology into healthcare information systems makes documentation integrity crucial to operational success. Here are three best practices for managing the CDI process at your facility:

1. Teach Nursing Staff the “Why” Behind CDI

Nurses documenting hundreds of data points per shift may see the creation of high-integrity documentation as a distraction from bedside care. This can foster low-integrity documentation practices, such as checking assessment workflow boxes without adding any optional findings to further illuminate the clinical picture that was witnessed.

Within this mindset, auditor queries may be seen as distractions related more to billing than the wellbeing of the patient. Provide training to share the ways that accurate and thorough documentation actually helps the patient, not just the facility’s billing procedures.

2. Define Clear Boundaries for Technology-Supported Workflows

Clinicians who are adapting to changing documentation practices in the work setting may not be aware of the related legal and ethical risks. When introducing technical tools to your facility’s documentation workflows, such as ambient AI, explain how the technology should and shouldn’t be used.

For example, teach nursing staff that using an EHR’s copy-forward function for assessment workflows creates falsified documentation if any of the charted data points are misrepresentations of the current clinical picture. Rather than improving efficiency, this workaround creates a risk of the violation of nursing professional standards.

3. Implement a CDI Training Program

Your facility’s documentation standards are unique, as are the staff members responsible for working together to record accurate clinical stories for their patients. Promote teamwork and clinician buy-in with training that explains your standards and workflow, such as:

• How to collaborate with clinical documentation specialists and nurse auditors.
• How your organization’s medical coding and billing process works.
• Clinical documentation integrity examples showcasing strong assessments and clinical notes.
• Case reviews that demonstrate the impact of low- and high-integrity documentation.

This can help healthcare workers create strong documentation that results in accurate charges to payers. For example, after implementation of a CDI curriculum, one surgical department had an estimated $4.7 million in increased charges and an 85% decrease in delinquent charting.

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Upholding clinical documentation integrity in the midst of a changing tech landscape is just one of the challenges facing healthcare leaders today. Looking for extra support? Our expert-backed healthcare resources provide streamlined information and updates that are designed to help you lead.