{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,11]],"date-time":"2026-02-11T12:48:19Z","timestamp":1770814099356,"version":"3.50.1"},"reference-count":26,"publisher":"American Health Information Management Association","issue":"1","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Adv Health Inf Sci Pract"],"published-print":{"date-parts":[[2025,6,18]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Accurate clinical documentation is essential for patient care, interdisciplinary communication, quality metrics reporting, and hospital reimbursement. Many hospitals face significant revenue losses due to inadequate or incomplete documentation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A retrospective chart review was conducted at a 250-bed community hospital in Queens, NY, analyzing surgical coding queries from January 2021 to December 2023. Before 2021, clinical documentation improvement (CDI) queries were randomly assigned to residents or attendings. In 2021, a quality improvement initiative centralized queries to the administrative chief resident, who facilitated resolutions. Data, including query volume and response times, were extracted from 3M CDI software.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>A total of 701 charts were reviewed for the study period. Prior to the intervention, CDI queries averaged 18 per month with a 67% response rate within 24 hours. Following centralization in 2021, query volume decreased to 9 per month by 2023, and the 24-hour response rate improved to 97%. The implementation of standardized templates and real-time coding reviews contributed to these improvements.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Centralizing CDI queries and integrating structured interventions into surgical training programs significantly improved documentation accuracy and response times. Enhanced collaboration between residents and CDI specialists positively impacted workflow efficiency, patient care, and hospital financial outcomes.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.63116\/pmcy2154","type":"journal-article","created":{"date-parts":[[2025,6,18]],"date-time":"2025-06-18T11:14:01Z","timestamp":1750245241000},"source":"Crossref","is-referenced-by-count":0,"title":["Clinical Document Improvement in Surgical Residency Training"],"prefix":"10.63116","volume":"1","author":[{"given":"Jane","family":"Tian","sequence":"first","affiliation":[{"name":"Surgery Flushing Hospital Medical Center https:\/\/dx.doi.org\/https:\/\/ror.org\/03ne66j56"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jonathan","family":"Mejia","sequence":"additional","affiliation":[{"name":"Surgery Flushing Hospital Medical Center https:\/\/dx.doi.org\/https:\/\/ror.org\/03ne66j56"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alexander","family":"Schaal","sequence":"additional","affiliation":[{"name":"Surgery Flushing Hospital Medical Center https:\/\/dx.doi.org\/https:\/\/ror.org\/03ne66j56"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Philippe","family":"Rousseau","sequence":"additional","affiliation":[{"name":"Clinical Documentation Flushing Hospital Medical Center https:\/\/dx.doi.org\/https:\/\/ror.org\/03ne66j56"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kazi","family":"Islam","sequence":"additional","affiliation":[{"name":"Clinical Documentation Flushing Hospital Medical Center https:\/\/dx.doi.org\/https:\/\/ror.org\/03ne66j56"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Esther","family":"Espinoza","sequence":"additional","affiliation":[{"name":"Clinical Documentation Flushing Hospital Medical Center https:\/\/dx.doi.org\/https:\/\/ror.org\/03ne66j56"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kellyann","family":"Inniss","sequence":"additional","affiliation":[{"name":"Medicine Ross University School of Medicine https:\/\/dx.doi.org\/https:\/\/ror.org\/02nd9e057"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Martine A.","family":"Louis","sequence":"additional","affiliation":[{"name":"Surgery Flushing Hospital Medical Center https:\/\/dx.doi.org\/https:\/\/ror.org\/03ne66j56"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nageswara","family":"Mandava","sequence":"additional","affiliation":[{"name":"Surgery Flushing Hospital Medical Center https:\/\/dx.doi.org\/https:\/\/ror.org\/03ne66j56"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"52461","reference":[{"issue":"5","key":"ref-441761","series-title":"J Vasc Surg","first-page":"1524","article-title":"A physician-led initiative to improve clinical documentation results in improved health care documentation, case mix index, and increased contribution margin","volume":"68","author":"Aiello","year":"2018","unstructured":"Aiello\n              F. A.\n            \n            \n              Judelson\n              D. R.\n            \n            \n              Durgin\n              J. M.\n            \n            \n           A physician-led initiative to improve clinical documentation results in improved health care documentation, case mix index, and increased contribution margin. J Vasc Surg. 2018;68(5):1524-1532. https:\/\/doi.org\/10.1016\/j.jvs.2018.02.038"},{"key":"ref-441762","series-title":"LinkedIn","article-title":"CDI specialists: The Unsung Heroes of the Healthcare Industry","author":"Health","year":"2022","unstructured":"Health\n              A.\n            \n           CDI specialists: The Unsung Heroes of the Healthcare Industry. LinkedIn\n          \n            7\n            12\n            2022\n2024-9-16\n          https:\/\/www.linkedin.com\/pulse\/cdi-specialists-unsung-heroes-healthcare-industry-ags-health"},{"issue":"12","key":"ref-441763","series-title":"JAMA Surg","first-page":"1073","article-title":"Three Observations for Improving Efforts in Surgical Quality Improvement","volume":"157","author":"Ko","year":"2022","unstructured":"Ko\n              C. Y.\n            \n            \n              Martin\n              G.\n            \n            \n              Dixon-Woods\n              M.\n            \n           Three Observations for Improving Efforts in Surgical Quality Improvement. JAMA Surg. 2022;157(12):1073-1074. https:\/\/doi.org\/10.1001\/jamasurg.2022.3122"},{"issue":"4","key":"ref-441764","series-title":"Critical Care Medicine","first-page":"579","article-title":"Clinical Documentation for Intensivists: The Impact of Diagnosis Documentation","volume":"48","author":"Sanderson","year":"2020","unstructured":"Sanderson\n              A. L.\n            \n            \n              Burns\n              J. P.\n            \n           Clinical Documentation for Intensivists: The Impact of Diagnosis Documentation. Critical Care Medicine. 2020;48(4):579-587. https:\/\/doi.org\/10.1097\/ccm.0000000000004200"},{"key":"ref-441765","series-title":"Asian J Psychiatry","first-page":"103268","article-title":"Improving the quality of structured clinical documentation in a child and adolescent psychiatry outpatient service: Findings from an audit cycle","volume":"77","author":"Khan","year":"2022","unstructured":"Khan\n              Y. S.\n            \n            \n              Albobali\n              Y.\n            \n            \n              Kamal\n              L. F.\n            \n           Improving the quality of structured clinical documentation in a child and adolescent psychiatry outpatient service: Findings from an audit cycle. Asian J Psychiatry. 2022;77\n          103268\nhttps:\/\/doi.org\/10.1016\/j.ajp.2022.103268"},{"issue":"3","key":"ref-441766","series-title":"J Healthc Qual","first-page":"e21","article-title":"Introducing a Clinical Documentation Specialist to Improve Coding and Collectability on a Surgical Service","volume":"41","author":"Castaldi","year":"2019","unstructured":"Castaldi\n              M.\n            \n            \n              McNelis\n              J.\n            \n           Introducing a Clinical Documentation Specialist to Improve Coding and Collectability on a Surgical Service. J Healthc Qual. 2019\n41(3):e21-e29. https:\/\/doi.org\/10.1097\/JHQ.0000000000000146"},{"issue":"2","key":"ref-441767","series-title":"Hosp Top","first-page":"27","article-title":"Implications of Clinical Documentation (In)Accuracy: A Pilot Study Among General Surgery Residents","volume":"95","author":"Garcia","year":"2017","unstructured":"Garcia\n              A.\n            \n            \n              Revere\n              L.\n            \n            \n              Sharath\n              S.\n            \n            \n              Kougias\n              P.\n            \n           Implications of Clinical Documentation (In)Accuracy: A Pilot Study Among General Surgery Residents. Hosp Top. 2017;95(2):27-31. https:\/\/doi.org\/10.1080\/00185868.2017.1300471"},{"key":"ref-441768","series-title":"ACDIS.","article-title":"The ROI of Revenue Cycle and CDI Education","author":"Cullen","year":"2022","unstructured":"Cullen\n              B.\n            \n           The ROI of Revenue Cycle and CDI Education. ACDIS.\n\n            2\n            2022\n2024-9-19\n          https:\/\/acdis.org\/articles\/roi-revenue-cycle-and-cdi-education"},{"issue":"12","key":"ref-441769","series-title":"Cureus","first-page":"e51274","article-title":"Enhancing Documentation Precision in Ophthalmic Surgery: A Quality Improvement Project","volume":"15","author":"Tanveer","year":"2023","unstructured":"Tanveer\n              S.\n            \n            \n              Khilji\n              M.\n            \n            \n              Gul\n              N.\n            \n            \n           Enhancing Documentation Precision in Ophthalmic Surgery: A Quality Improvement Project. Cureus\n            2023;15(12):e51274\nhttps:\/\/doi.org\/10.7759\/cureus.51274"},{"issue":"1","key":"ref-441770","series-title":"Health Inf Manag","first-page":"3","article-title":"What do we really want from clinical documentation improvement programs?","volume":"47","author":"Shepheard","year":"2018","unstructured":"Shepheard\n              J.\n            \n           What do we really want from clinical documentation improvement programs?. Health Inf Manag. 2018;47(1):3-5. https:\/\/doi.org\/10.1177\/1833358317712312"},{"issue":"3","key":"ref-441771","series-title":"Health Inf Manag","first-page":"99","article-title":"Documentation of clinical care in hospital patients' medical records: A qualitative study of medical students' perspectives on clinical documentation education","volume":"45","author":"Rowlands","year":"2016","unstructured":"Rowlands\n              S.\n            \n            \n              Coverdale\n              S.\n            \n            \n              Callen\n              J.\n            \n           Documentation of clinical care in hospital patients' medical records: A qualitative study of medical students' perspectives on clinical documentation education. Health Inf Manag. 2016;45(3):99-106. https:\/\/doi.org\/10.1177\/1833358316639448"},{"issue":"Winter","key":"ref-441772","series-title":"Perspect Health Inf Manag","first-page":"1f","article-title":"Surgical Precision in Clinical Documentation Connects Patient Safety, Quality of Care, and Reimbursement","volume":"13","author":"Kittinger","year":"2016","unstructured":"Kittinger\n              B. J.\n            \n            \n              Matejicka\n              A., 2nd\n            \n            \n              Mahabir\n              R. C.\n            \n           Surgical Precision in Clinical Documentation Connects Patient Safety, Quality of Care, and Reimbursement. Perspect Health Inf Manag\n            2016;13(Winter):1f."},{"issue":"4","key":"ref-441773","series-title":"J Surg Educ","first-page":"957","article-title":"POST-OP: A Strategy to Improve Clinical Documentation in the Early Postoperative Period","volume":"75","author":"Cromwell","year":"2018","unstructured":"Cromwell\n              P. M.\n            \n            \n              Flood\n              M.\n            \n            \n              O Connell\n              E.\n            \n            \n           POST-OP: A Strategy to Improve Clinical Documentation in the Early Postoperative Period. J Surg Educ. 2018;75(4):957-963. https:\/\/doi.org\/10.1016\/j.jsurg.2018.01.005"},{"issue":"5","key":"ref-441761","series-title":"J Vasc Surg","first-page":"1524","article-title":"A physician-led initiative to improve clinical documentation results in improved health care documentation, case mix index, and increased contribution margin","volume":"68","author":"Aiello","year":"2018","unstructured":"Aiello\n              F. A.\n            \n            \n              Judelson\n              D. R.\n            \n            \n              Durgin\n              J. M.\n            \n            \n           A physician-led initiative to improve clinical documentation results in improved health care documentation, case mix index, and increased contribution margin. J Vasc Surg. 2018;68(5):1524-1532. https:\/\/doi.org\/10.1016\/j.jvs.2018.02.038"},{"key":"ref-441762","series-title":"LinkedIn","article-title":"CDI specialists: The Unsung Heroes of the Healthcare Industry","author":"Health","year":"2022","unstructured":"Health\n              A.\n            \n           CDI specialists: The Unsung Heroes of the Healthcare Industry. LinkedIn\n          \n            7\n            12\n            2022\n2024-9-16\n          https:\/\/www.linkedin.com\/pulse\/cdi-specialists-unsung-heroes-healthcare-industry-ags-health"},{"issue":"12","key":"ref-441763","series-title":"JAMA Surg","first-page":"1073","article-title":"Three Observations for Improving Efforts in Surgical Quality Improvement","volume":"157","author":"Ko","year":"2022","unstructured":"Ko\n              C. Y.\n            \n            \n              Martin\n              G.\n            \n            \n              Dixon-Woods\n              M.\n            \n           Three Observations for Improving Efforts in Surgical Quality Improvement. JAMA Surg. 2022;157(12):1073-1074. https:\/\/doi.org\/10.1001\/jamasurg.2022.3122"},{"issue":"4","key":"ref-441764","series-title":"Critical Care Medicine","first-page":"579","article-title":"Clinical Documentation for Intensivists: The Impact of Diagnosis Documentation","volume":"48","author":"Sanderson","year":"2020","unstructured":"Sanderson\n              A. L.\n            \n            \n              Burns\n              J. P.\n            \n           Clinical Documentation for Intensivists: The Impact of Diagnosis Documentation. Critical Care Medicine. 2020;48(4):579-587. https:\/\/doi.org\/10.1097\/ccm.0000000000004200"},{"key":"ref-441765","series-title":"Asian J Psychiatry","first-page":"103268","article-title":"Improving the quality of structured clinical documentation in a child and adolescent psychiatry outpatient service: Findings from an audit cycle","volume":"77","author":"Khan","year":"2022","unstructured":"Khan\n              Y. S.\n            \n            \n              Albobali\n              Y.\n            \n            \n              Kamal\n              L. F.\n            \n           Improving the quality of structured clinical documentation in a child and adolescent psychiatry outpatient service: Findings from an audit cycle. Asian J Psychiatry. 2022;77\n          103268\nhttps:\/\/doi.org\/10.1016\/j.ajp.2022.103268"},{"issue":"3","key":"ref-441766","series-title":"J Healthc Qual","first-page":"e21","article-title":"Introducing a Clinical Documentation Specialist to Improve Coding and Collectability on a Surgical Service","volume":"41","author":"Castaldi","year":"2019","unstructured":"Castaldi\n              M.\n            \n            \n              McNelis\n              J.\n            \n           Introducing a Clinical Documentation Specialist to Improve Coding and Collectability on a Surgical Service. J Healthc Qual. 2019\n41(3):e21-e29. https:\/\/doi.org\/10.1097\/JHQ.0000000000000146"},{"issue":"2","key":"ref-441767","series-title":"Hosp Top","first-page":"27","article-title":"Implications of Clinical Documentation (In)Accuracy: A Pilot Study Among General Surgery Residents","volume":"95","author":"Garcia","year":"2017","unstructured":"Garcia\n              A.\n            \n            \n              Revere\n              L.\n            \n            \n              Sharath\n              S.\n            \n            \n              Kougias\n              P.\n            \n           Implications of Clinical Documentation (In)Accuracy: A Pilot Study Among General Surgery Residents. Hosp Top. 2017;95(2):27-31. https:\/\/doi.org\/10.1080\/00185868.2017.1300471"},{"key":"ref-441768","series-title":"ACDIS.","article-title":"The ROI of Revenue Cycle and CDI Education","author":"Cullen","year":"2022","unstructured":"Cullen\n              B.\n            \n           The ROI of Revenue Cycle and CDI Education. ACDIS.\n\n            2\n            2022\n2024-9-19\n          https:\/\/acdis.org\/articles\/roi-revenue-cycle-and-cdi-education"},{"issue":"12","key":"ref-441769","series-title":"Cureus","first-page":"e51274","article-title":"Enhancing Documentation Precision in Ophthalmic Surgery: A Quality Improvement Project","volume":"15","author":"Tanveer","year":"2023","unstructured":"Tanveer\n              S.\n            \n            \n              Khilji\n              M.\n            \n            \n              Gul\n              N.\n            \n            \n           Enhancing Documentation Precision in Ophthalmic Surgery: A Quality Improvement Project. Cureus\n            2023;15(12):e51274\nhttps:\/\/doi.org\/10.7759\/cureus.51274"},{"issue":"1","key":"ref-441770","series-title":"Health Inf Manag","first-page":"3","article-title":"What do we really want from clinical documentation improvement programs?","volume":"47","author":"Shepheard","year":"2018","unstructured":"Shepheard\n              J.\n            \n           What do we really want from clinical documentation improvement programs?. Health Inf Manag. 2018;47(1):3-5. https:\/\/doi.org\/10.1177\/1833358317712312"},{"issue":"3","key":"ref-441771","series-title":"Health Inf Manag","first-page":"99","article-title":"Documentation of clinical care in hospital patients' medical records: A qualitative study of medical students' perspectives on clinical documentation education","volume":"45","author":"Rowlands","year":"2016","unstructured":"Rowlands\n              S.\n            \n            \n              Coverdale\n              S.\n            \n            \n              Callen\n              J.\n            \n           Documentation of clinical care in hospital patients' medical records: A qualitative study of medical students' perspectives on clinical documentation education. Health Inf Manag. 2016;45(3):99-106. https:\/\/doi.org\/10.1177\/1833358316639448"},{"issue":"Winter","key":"ref-441772","series-title":"Perspect Health Inf Manag","first-page":"1f","article-title":"Surgical Precision in Clinical Documentation Connects Patient Safety, Quality of Care, and Reimbursement","volume":"13","author":"Kittinger","year":"2016","unstructured":"Kittinger\n              B. J.\n            \n            \n              Matejicka\n              A., 2nd\n            \n            \n              Mahabir\n              R. C.\n            \n           Surgical Precision in Clinical Documentation Connects Patient Safety, Quality of Care, and Reimbursement. Perspect Health Inf Manag\n            2016;13(Winter):1f."},{"issue":"4","key":"ref-441773","series-title":"J Surg Educ","first-page":"957","article-title":"POST-OP: A Strategy to Improve Clinical Documentation in the Early Postoperative Period","volume":"75","author":"Cromwell","year":"2018","unstructured":"Cromwell\n              P. M.\n            \n            \n              Flood\n              M.\n            \n            \n              O Connell\n              E.\n            \n            \n           POST-OP: A Strategy to Improve Clinical Documentation in the Early Postoperative Period. J Surg Educ. 2018;75(4):957-963. https:\/\/doi.org\/10.1016\/j.jsurg.2018.01.005"}],"container-title":["Advances in Health Information Science and Practice"],"original-title":[],"link":[{"URL":"https:\/\/ahisp.kglmeridian.com\/view\/journals\/3995\/1\/1\/article-PMCY2154.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/ahisp.kglmeridian.com\/downloadpdf\/journals\/3995\/1\/1\/article-PMCY2154.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/ahisp.kglmeridian.com\/downloadpdf\/journals\/3995\/1\/1\/article-PMCY2154.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,11]],"date-time":"2026-02-11T00:55:36Z","timestamp":1770771336000},"score":1,"resource":{"primary":{"URL":"https:\/\/ahisp.kglmeridian.com\/view\/journals\/3995\/1\/1\/article-PMCY2154.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025]]},"references-count":26,"journal-issue":{"issue":"1"},"URL":"https:\/\/doi.org\/10.63116\/pmcy2154","relation":{},"ISSN":["3066-5825"],"issn-type":[{"value":"3066-5825","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025]]}}}