Clincal Documentation Professional

There has been much discussion recently regarding clinical validation and with good reason. Every patient, whether in the hospital or the myriad of other venues where one presents for care, has a right to receive high quality health care with a medical record that outlines this process – this is a point all can agree upon.

Once the patient leaves the care of the provider, the only true and legal piece of communication that remains is the medical record. It is the responsibility of every person who enters information in the medical record to ensure it is precise and complete. As the record is reviewed, both gap identification and clinical validation of the documentation are being performed.

Documentation gap identification and ensuing clarification is performed to ensure a thorough chronicle of events in the medical record and clinical validation is performed to ensure a complete medical record. Clinical validation can be defined as “the use of clinical criteria to support the reported codes,” according to the 2017 Guide to Clinical Validation, Documentation and Coding: Validating Code Assignments with Clinical Documentations, and is not a new concept. There are multiple credible and official sources that promote the use of clinical criteria, which indicate that gap identification and clinical validation are intertwined by the utilization of clinical criteria.

You may be wondering how the process of clinical validation occurs alongside gap identification during a concurrent review? Essentially, the clinical criteria noted for gap identification are also used for clinical validation. Gap identification and clinical validation are so intertwined that an individual may not realize they are performing clinical validation because, to identify a gap, one must first validate the documentation currently in the medical record. It has been noted that if an individual can look at signs, symptoms, and results and appropriately translate as relevant clinical criteria to develop a clarification, which is gap identification, then the opposite must be true – the individual must be able to note the documentation of a diagnosis or condition and isolate the relevant clinical criteria in the record, which describes clinical validation. For example, how can a gap of the specificity of a type of pneumonia be identified without first clinically validating the diagnosis of pneumonia, or how can a gap of the acuity and/or type of congestive heart failure be identified without first validating that the patient does indeed have congestive heart failure?

A review of the entire medical record is the key to successful clinical validation. A thorough record review involves more than acknowledging diagnoses that the provider has documented; it involves gap identification and clinical validation simultaneously. There are many models to describe a record review, and one that has proven to be successful is to follow the same pathway a provider takes during a history and physical. To clarify, this means that the CDI professional is looking at the same elements that the provider noting during an H&P, this does not mean the reviewer should only look at the H&P during a record review, for the 2017 ICD-10-CM Official Guidelines for Coding and Reporting states, “the entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”

Begin by looking at the chief complaint or the reason the patient is presenting for care. While this likely won’t be the principal diagnosis, it will set the pace by providing a clue as to if this will be a path down one road, or many roads. For example, abdominal pain will send the reviewer down many roads, due to the multiple conditions that share abdominal pain as a clinical indicator.

If the patient was admitted via ambulance through the emergency department (ED), reviewing the ambulance notes, in addition to the triage, nursing and physician notes can yield valuable information regarding the history of present illness. Note the medication list – compare home and current medications. Were there any changes (additions, discontinuations, dosage/route)? Look for documentation to justify the administration of all medications.

Review the laboratory results, radiology reports and other tests that were administered beginning with the arrival to the ED, and compare to documentation of past results and reports that could be criteria to support and/or indicate a gap regarding an acute or chronic condition.

Next, look at the physical examination (PE) findings by all who have examined the patient, quickly noting both the abnormal and the significant normals. Significant normals are the normal results that would rule out or invalidate certain conditions. For example, documentation of, “no cough; no sob; lung sounds, oxygenation, and mentation normal; chest x-ray normal” would indicate a normal respiratory system, which would appear to clinically rule out a respiratory diagnosis.

This model of record review doesn’t advocate looking at the assessment for any provider diagnoses until after all other information has been reviewed. During the record review, the CDI professional is gathering the information and those facts are beginning to form a picture of the clinical scenario in their mind, just as it would for a character in a book as it is read. As the abnormal criteria is noted, conditions most often associated with that criteria come forth as possibilities, and as the significant normals are identified, other possibilities are eliminated until what remains is a small group of possible conditions.

This pathway has proven to be successful because it was found that if the CDI professional first looked at the diagnoses the provider had documented, the value of critical thinking is lost and important criteria may be missed that could identify a gap or clinically validate the documentation. For example, if a provider writes ‘pneumonia’ in their diagnosis list and the reviewer first notes this diagnosis, the diagnosis of pneumonia will be in their mind and they may miss documentation of the recent history of coughing during meals, a chest x-ray report showing a RLL infiltrate, or orders changing the home medications from PO to IV or IM as they seek to clinical validate the diagnosis of pneumonia, and a potential gap could be overlooked.

By thoroughly reviewing the entire record following this format, not only are gaps in documentation being identified, clinical validation is also being performed seamlessly for those diagnoses already documented. It is easy to see that clinical validation and gap identification are intertwined, and as such are integral parts of the role of a Clinical Documentation Improvement professional.

Respectfully submitted,
Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP
Director of Education


Optum360. 2017 Guide to clinical validation, documentation and coding: Validating code assignments with clinical documentations. Introduction. Optum360, LLC.

Optum 360. 2017.ICD-10-CM Official Guidelines for Coding and Reporting.

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