Template

Clinical Documentation Improvement (CDI) Synchronous Chart Review Template

Interactive structured chart-review form to guide CDI specialists and clinicians during synchronous case reviews. Captures clinical indicators, missing documentation cues, suggested query language, urgency, coding impact, and a follow-up tracking log. Saves submissions for follow-up, reporting, and analytics.

Interactive Tool

CDI Synchronous Chart Review

Use this structured chart-review form during synchronous CDI reviews. The form helps capture the clinical rationale, missing documentation, suggested query language, urgency, coding impact, and follow-up actions so queries are clear, prompt, and tracked to completion.

Optional unique identifier (auto-id may be provided by the system).
Enter the date of the synchronous review.
Add MRN to support later reconciliation with EHR extracts if available.
Brief summary of the primary reason for admission or visit.
List findings, labs, imaging, vitals, treatments, or symptoms that support the documentation concern. Be specific (e.g., troponin values, oxygen requirement, wound characteristics).
Use concise, non-leading language. Example: 'Please clarify whether the patient's acute respiratory failure was present on admission and required oxygen or ventilatory support. Documentation examples: ...'
If follow-up required, set a target date.
Record subsequent actions: dates, who was contacted, results. Useful for audit and closure.
Use this field to capture context, teaching points, or items for broader process improvement.
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