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Documentation Index

Fetch the complete documentation index at: https://docs.medera.info/llms.txt

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Category: Documentation & Coding  ·  Signals: Clinical note · Specialty rule-set · Severity qualifiers · Audit trail
Review notes for clarity, completeness, and coding-grade specificity.

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Overview

The CDI Agent runs concurrent documentation review on every note — surfacing missing severity qualifiers, weak specificity, and gaps the coder will query for. Every suggestion is a clinical query, not a code change, and the clinician’s accept / reject decision is logged for audit.

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How this agent works

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Configuration

This agent takes the following configuration from your practice settings:
  • Specialty CDI rule-set (BH, primary care, others)
  • Practice documentation thresholds
  • Audit retention and rationale requirements
  • Sign-off enforcement (advisory vs. blocking)

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Execution

At runtime, the agent executes the following steps:
  1. Reads the note against the CDI rule-set for the specialty
  2. Surfaces missing specificity (uncomplicated → with severity)
  3. Suggests language clinicians can paste into the note
  4. Logs the rationale for every suggestion
  5. Records the clinician’s accept/reject decision

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Composable experts

The Clinical Documentation Improvement Agent bundles the following experts from the registry:
ExpertRole
CDI Rule ExpertSpecialty rule-set adherence
Specificity ExpertHighest defensible diagnosis specificity
Severity & Acuity ExpertCapture of clinically relevant qualifiers
Audit Trail ExpertEvery suggestion logged with rationale

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Typical use cases

  • Catch missing severity qualifiers before billing
  • Strengthen documentation specificity without retraining
  • Document the rationale behind every CDI query
  • Run concurrent CDI on every note, not the audit sample

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Compliance & safety guarantees

  • CDI suggestions are surfaced as clinical queries, never code changes
  • Every suggestion logs the rationale and the rule it tested
  • Audit retention follows the practice policy by default

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Tags

CDI · Specificity · Severity · Audit trail

Agentic Framework Overview

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