Evidence map›Paper›PMID 41333332›Full record

ArticleAdvances in health information science and practice2025

The Impact of Clinical Documentation Integrity Programs on Diagnosis Documentation.

Amy L Sanderson, Lucinda Lo, Wendy Arafiles, Ara Balkian, Daxa P Clarke, Paola Dees, Corinna M Foley, Patrice Melvin, Steven J Staffa, David Zurakowski and 1 more

Abstract read
In one paragraph

Article in Advances in health information science and practice, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.

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0cells of the map it votes in
1citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

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3 · Its place in the literature

Who cites it

1 citing paper in PubMed.

  1. Article
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

11 authors.

Amy L SandersonDepartment of Anesthesiology, Critical Care and Pain Medicine Boston Children's Hospital.ORCID https://orcid.org/0000-0003-3886-0666
Lucinda LoDepartment of Pediatrics Children's Hospital of Philadelphia.
Wendy ArafilesDivision of Hospital Medicine Phoenix Children's Hospital.
Ara BalkianDivision of Hospital Medicine Children's Hospital Los Angeles.
Daxa P ClarkeDivision of Hospital Medicine Phoenix Children's Hospital.
Paola DeesDivision of Pediatric Hospital Medicine Johns Hopkins All Children's Hospital.
Corinna M FoleyDepartment of Patient Care Operations Boston Children's Hospital.
Patrice MelvinCenter for Applied Pediatric Quality Analytics Boston Children's Hospital.
Steven J StaffaDepartment of Anesthesiology, Critical Care and Pain Medicine Boston Children's Hospital.
David ZurakowskiDepartment of Anesthesiology, Critical Care and Pain Medicine Boston Children's Hospital.
Sheilah SnyderDepartment of Pediatrics Children's Nebraska.

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

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 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.

Indexed as

DocumentationElectronic Health RecordsChildDiagnosis-Related GroupsHospitals, PediatricHumanscase mix indexClinical Documentation Integritycomplexity

Identifiers

PMID41333332
PMCPMC12637214

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.