Coded data
Coders translate documentation into reportable codes. What is not documented cannot be coded or reported.
Guide · Reviewed 2026-11-01
Clinical documentation integrity (CDI): what it is and how AI fits
Clinical documentation integrity (CDI) makes sure the medical record completely and accurately reflects the patient's conditions and care. CDI specialists review records and, when documentation is unclear, send compliant queries to providers. Arkangel AI supports CDI teams by reviewing charts against configured rules and citing the chart text behind each possible gap for a person to validate.
What CDI specialists do
According to ACDIS, CDI specialists review patient medical records and assess whether all conditions and treatments are documented, so the record shows the severity of the patient's illness and the extent of care required. When documentation is unclear or deficient, they query physicians for clarification, and they act as the bridge between health information management and clinical staff.
Most CDI specialists are registered nurses, and the field also includes coding professionals, physicians and quality improvement staff. The "I" in CDI used to stand for "improvement"; ACDIS now uses "integrity" to stress a complete and accurate record that reflects the clinical truth.
Why documentation integrity matters
Quality reporting
Quality measures such as HEDIS increasingly rely on structured clinical data in the record.
Risk adjustment
Risk-adjusted payment models depend on diagnoses that are documented and supported in the medical record.
Audits
Payers and auditors check that billed and reported diagnoses are supported by documentation.
Compliant queries: the 2026 ACDIS/AHIMA update
ACDIS and AHIMA published the 2026 update of their Guidelines for Achieving a Compliant Query Practice, which replaces the 2022 edition. The core principles:
- Queries are based on actual clinical indicators in the record.
- Queries are nonleading and do not refer to reimbursement.
- The provider keeps room to use independent clinical judgment and reach their own conclusion.
- A query is still a query whatever technology creates it: a system prompt, alert or “smart suggestion” that offers a specific diagnosis for a specific encounter must meet the same standards.
- Organizations should not assume that a vendor-supplied or EHR-integrated tool produces compliant queries, and should keep overseeing those tools after rollout.
Summary of AHIMA Journal, “Guidelines for Achieving a Compliant Query Practice: What's New in the 2026 Update” (September 22, 2026). Read the full guidelines before changing your query process.
Where AI chart review fits in a CDI program
- 1
Configure the rules
Choose the documentation, coding and risk-adjustment criteria your CDI and coding teams already use.
- 2
Review the records
Arkangel AI reads the charts you make available and flags possible documentation gaps, citing the chart text and the rule behind each one.
- 3
A person validates
Each finding stays “Not verified” until a CDI specialist or coder accepts or dismisses it. Arkangel AI does not send queries to providers on its own.
- 4
Query under your policy
If a query is needed, your team writes it under your compliant query policy, based on the clinical indicators in the record.
Clinical documentation integrity FAQ
What is clinical documentation integrity?
Clinical documentation integrity (CDI) is the practice of making sure the medical record completely and accurately reflects each patient's conditions, severity and care. CDI specialists review records and, when documentation is unclear or incomplete, ask providers for clarification through compliant queries, so coding, quality reporting and payment rest on accurate data.
What is the difference between CDI and clinical documentation improvement?
They describe the same field. The "I" in CDI originally stood for improvement; ACDIS, the Association of Clinical Documentation Integrity Specialists, now uses integrity to emphasize a complete and accurate record that reflects the clinical truth, rather than only improving documentation for coding or reimbursement purposes.
Who works as a CDI specialist?
According to ACDIS, most CDI specialists are registered nurses, and the field also includes coding professionals, physicians and quality improvement staff. The key skill is clinical knowledge: recognizing diagnoses and treatments that are not clearly documented and educating busy physicians on documentation requirements in a compliant way.
What makes a CDI query compliant?
Under the ACDIS/AHIMA 2026 guidelines, a compliant query is based on clinical indicators in the record, is nonleading, does not mention reimbursement and lets the provider reach an independent conclusion. The same standards apply to prompts generated by software, so AI or EHR suggestions need ongoing oversight by query professionals.
Can AI do clinical documentation integrity?
AI can help CDI teams review more charts by flagging possible documentation gaps and citing the text behind them, but people should decide. In Arkangel AI, every finding names the rule and the chart text and stays not verified until a CDI specialist or coder accepts it; queries follow your own policy.
See cited chart review for your CDI team
Book a 30-minute consultation. We walk through sample findings on a synthetic record and how your team validates each one before anything reaches a provider.
Sources
- ACDIS: What is a CDI specialist? (CDI Week fact sheet) — Read 2026-11-01.
- ACDIS: note on focusing on integrity — Read 2026-11-01.
- ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice, 2026 update — Read 2026-11-01.
- AHIMA Journal: what's new in the 2026 query practice update (Sep 22, 2026) — Read 2026-11-01.
Last reviewed: . This guide summarizes public ACDIS and AHIMA information and is not affiliated with or endorsed by either organization. It is not coding, legal or compliance advice. Arkangel AI findings require validation by your team; coding, payment and audit outcomes are not guaranteed.