Policies & Procedures

The Clinical Documentation Improvement (CDI) Roadmap is intended to provide industry standards and best practices for the establishment and ongoing maintenance of CDI programs.

This sample was re-reviewed and approved by the ACDIS Resource Library Committee in 2023. The committee...

This sample CDI telecommuting policy was provided by Lee Ann Landon, BSN, CCMC, CCDS, CDI manager at Honor-Health in Scottsdale, Arizona.

This sample has been reviewed and approved by the Resource Library Committee in 2023. The committee recommends that if a program uses...

These sample telecommuting policy and work agreement were provided by Bonnie Epps-Long, MSN, RN, the director of CDI at Emory Healthcare in Atlanta, Georgia.

These samples have been reviewed and approved by the Resource Library Committee in 2023. The committee recommends...

This sample was reviewed and approved by the ACDIS Resource Library Committee in 2023. The committee argued that if you use this resource, take not that it utilizes an old compliant query practice.

This sample unanswered query escalation policy was provided by Lee Ann Landon, BSN...

This sample was reviewed and approved by the ACDIS Resource Library Committee in 2023.

Thanks to Valerie Parent, RN, BSN, CCDS, CCRN-K, for donating the attached outpatient CDI record review tracking tool. Parent is the clinical documentation improvement manager at Eastern Maine Medical...

Thanks to Valerie Parent, RN, BSN, CCDS, CCRN-K, for donating the attached outpatient CDI monthly tracking tool. Parent is the clinical documentation improvement manager at Eastern Maine Medical Center in Bangor, Maine. She can be reached at vparent@emhs.org...

This sample was reviewed and approved by the ACDIS Resource Library Committee in 2023. The committee noted that if you use this resource, the basic format needs to be adjusted to the specificities of your organization.

Karen Chase, MS, BSN, RN, CCDS, assistant director of clinical...

This sample was reviewed and approved by the ACDIS Resource Library Committee in 2023. The committee noted that, though this template would be useful for those just starting out in mortality reviews, it would also require customized columns (ex. columns containing quality reviews) to reflect...

Ronna Mahlen composed this simple, five-question, CDI specialist query audit that your team can use to conduct regular peer reviews or self audits. She originally shared her tool on CDI Talk.

The attached Unanswered query and query conflict escalation policy is a sample policy for handling unanswered physician queries and/or CDI/coding conflicts that require resolution. The policy is courtesy of Lynne Spryszak, RN, CCDS, CPC-A, CDI education director for HCPro, Inc.