5 Key Signs Your Clinical Documentation Improvement (CDI) Program Needs an Evaluation | CDI LinkIt

Clinical Documentation Improvement (CDI) programs are essential to delivering accurate, compliant, and effective healthcare. A well-functioning CDI program strengthens documentation quality, supports appropriate reimbursement, and enhances patient outcomes. However, as healthcare environments evolve, even the strongest CDI programs need regular evaluation.

At CDI LinkIt, we work with hospitals and health services across Queensland, NSW, and Australasia to strengthen the impact of their CDI efforts. A successful CDI program is not static. It requires consistent monitoring, review, and refinement to remain effective.

If you are unsure whether your program is performing at its best, here are five key signs that indicate it may be time for a CDI program evaluation.

1. Persistent Documentation Gaps

Ongoing documentation gaps are a common sign that your CDI strategy needs reviewing. These gaps may present as vague or incomplete clinical notes, missing secondary diagnoses, or inconsistent terminology.

When documentation lacks specificity, coders cannot assign accurate codes. Instead of making assumptions, they must query clinicians for clarification. This process delays coding, slows reimbursement, and adds administrative burden to both clinical and health information teams.

If you are seeing an increase in unresolved queries or audit flags, it is time to assess whether your documentation practices and CDI processes are truly supporting quality clinical data.

2. Increased Coding Errors or Unexplained DRG Shifts

An uptick in coding errors or changes in Diagnosis-Related Group (DRG) assignment can indicate that documentation is not aligning with coding guidelines. This disconnect may be caused by outdated documentation habits, clinician uncertainty, or gaps in CDI education.

Effective CDI programs support accurate, defensible coding. If your coders are struggling to assign codes due to unclear documentation or are frequently requesting clarification, a structured CDI program review can identify where improvements are needed, whether that is in training, documentation templates, or team collaboration.

3. Low or Declining Clinician Engagement

Clinician engagement is crucial to the success of any CDI initiative. If you notice slower query response times, limited involvement in education, or minimal interaction with CDI specialists, your program’s impact may be at risk.

Disengagement is often a symptom of deeper issues such as unclear program goals, limited communication, or negative past experiences. A thorough CDI program assessment can uncover these barriers and provide strategies to rebuild trust and collaboration between clinical staff and the CDI team.

4. Stagnant CDI Performance Metrics

Flatlining performance metrics are another indicator that your CDI program may no longer be driving improvement. If indicators such as case mix index (CMI), query response rates, or severity of illness and risk of mortality capture have remained unchanged, it may be time for a strategic reassessment.

A CDI evaluation helps uncover opportunities for growth, such as expanding into new specialties, refining key performance indicators (KPIs), or updating your query templates to reflect current clinical language and coding requirements.

5. Unfavourable Audit Outcomes

Frequent audit issues, whether from internal reviews, external audits, or funding body assessments, are a clear signal that something in your documentation and coding ecosystem needs attention.

Because clinical documentation improvement is central to audit readiness, these outcomes may point to inconsistent practices, ineffective queries, or gaps in CDI staff training. A targeted evaluation can help you identify and address the root causes before they escalate into compliance risks.

Is It Time to Reassess Your CDI Program?

A CDI program evaluation is not about identifying failure. It is about recognising that, like any clinical process, documentation improvement must evolve to stay relevant, compliant, and effective.

At CDI LinkIt, we offer expert-led CDI evaluations tailored to the needs of healthcare organisations across Australasia. Our approach helps you uncover hidden challenges, re-engage your teams, and drive better outcomes through more accurate documentation.

If any of these warning signs sound familiar, now is the time to take a closer look at your program’s performance.

Learn more about how CDI LinkIt supports CDI programs here.

Let us help you turn red flags into real results.