The Clinical Documentation Improvement specialist at Wildcat Hospital


You are the Clinical Documentation Improvement specialist at Wildcat Hospital. Your CDI team has asked you to create a closed record review checklist for the physical examination completed by the attending physician.

Using Excel or another spreadsheet, I want you to create an audit to analyze the completion of a physical exam. The overall goal is to be able to assess and analyze this audit, so you want your data to have the ability to be aggregated. I recommend students to make each row a yes/no question which covers the timely completion of the physical exam by CMS and The Joint Commission and the required physical exam components.

Create your audit so it can be used for 5 health records (columns). You do not need to fill in the audit form (marking yes/no), just create the audit.

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