Patient Documentation — Portfolio Projects
Build projects that demonstrate clinical documentation improvement (CDI) judgment — recognizing documentation gaps and resolving them compliantly — the core skill this specialty is built on.
Project 1: Compliant Physician Query Template Library
Level: Beginner | Time: 2 days
Build a library of physician query templates for common documentation-gap scenarios (e.g., unspecified diagnosis, missing acuity/laterality, clinical indicators without a stated diagnosis), written to be compliant and non-leading.
Steps
Skills Demonstrated
Note
Physician query compliance standards (query construction guidance) are maintained by organizations like AHIMA/ACDIS and can be refined over time — verify current query-compliance guidance against current AHIMA/ACDIS standards before treating a specific query's wording as a settled compliant template.
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Project 2: SOAP-Note-to-Code Documentation Crosswalk
Level: Intermediate | Time: 3-4 days
Take 10+ SOAP-format clinical notes and evaluate whether the documentation supports the level of specificity needed for accurate coding — flagging gaps rather than coding around them.
Steps
Skills Demonstrated
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Project 3: Documentation Gap Audit Portfolio
Level: Advanced | Time: 1 week
A comprehensive audit of 15-20 realistic clinical documentation samples, identifying every documentation gap that would block accurate, specific coding and drafting the appropriate compliant query for each.
Steps
Skills Demonstrated
Portfolio Artifact Name
documentation-gap-audit
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Tips for Great Projects
Practice recognizing gaps, not just filling them in. The core CDI skill is noticing when documentation doesn't support a specific code — that's a judgment call worth demonstrating explicitly.
Write every query as genuinely open, not leading. A query that only offers the diagnosis you suspect is the classic compliance failure — show you know the difference.
Connect documentation gaps to their coding consequence. "This gap matters because it's the difference between code X and unspecified code Y" is a much stronger portfolio artifact than a bare gap list.
Treat compliance standards as something to verify, not assume. Query-compliance guidance is maintained by AHIMA/ACDIS and can be refined — check current guidance rather than relying on memory.