Which item is an example of unstructured data in a CDI environment?

• A. ICD-10-CM code
• B. Progress note
• C. CPT code
• D. Lab value

Answer: (B)

The main concept here is the difference between unstructured narrative documentation and structured coded data in a CDI setting. Unstructured data is free-text or narrative content that doesn’t fit predefined data fields, making it harder to extract specific concepts without additional processing.

A progress note fits this as an example of unstructured data because it’s a clinician’s narrative description of the patient’s history, exam findings, assessment, and plan written in prose rather than in fixed, codified fields.

In contrast, ICD-10-CM codes and CPT codes are standardized, structured data used for reporting diagnoses and procedures. Lab values are typically stored as discrete numbers with units and reference ranges in fixed fields, which are also structured data. These structured formats make it easier to automate coding, reporting, and analytics.

So, the progress note is the unstructured data item in a CDI environment.