The Impact of Clinical Documentation Integrity Programs on Diagnosis Documentation.

Background: Clinical Documentation Integrity (CDI) programs aid in documentation of precise diagnoses. In this study, the authors assessed the rate at which certain diagnoses were present in the Pediatric Health Information System (PHIS) database and evaluated changes in the hospital-specific case mix index (CMI) pre- and post-CDI program inception at six children's hospitals. Methods: Between 2011 and 2017, CDI programs were implemented at six children's hospitals. The authors queried the PHIS database to compare the following diagnoses in 2010 and 2021: acute respiratory failure, chronic respiratory failure, ventilator dependence, dysphagia, malnutrition, and presence of a gastrostomy and/or jejunostomy (G/J) tube in patients with aspiration. Results: From 2010 to 2021, CMI increased at all hospitals. For all hospitals' inpatient encounters, the percentage of patients with acute respiratory failure and malnutrition increased (both p <0.001). Documentation of chronic respiratory failure increased (p < 0.001) and ventilator dependence decreased (p < 0.001) at all institutions. There were variations at the hospital level for capture of dysphagia, G/J and both diagnoses together. Conclusions: CMI increased and the rate of specific diagnoses in the PHIS database increased from 2010 to 2021, which corresponded to implementation of all institutions' CDI programs. Documentation of specific, clinically-relevant diagnoses in the medical record ensures optimal healthcare provider communication, proper severity of illness representation, appropriate hospital reimbursement, accurate quality metric reporting and database accuracy.