The Key to a Top Notch Clinical Documentation Program

This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.


By Jennifer A. Daly, MSN, RN, CCDS, CDIP

 

Patients come to hospitals for a variety of reasons. Some are minor, while others can be life threatening. As a clinical documentation improvement (CDI) professional, highlighting these key conditions in the medical record is imperative to ensuring your healthcare facility receives proper credit for the allocation of care that was provided to these patients. In order to successfully do this, a CDI professional needs to have physicians who are willing to provide the key documentation that shows the severity of their patients’ illnesses.

Having been a CDI professional for the past 12 years, I have learned that there are several things CDI programs can do to help obtain and maintain physician buy-in. The first place to start is during new physician orientation. Every facility has some type of on-boarding process for new physicians. Find out where that is and provide a 10-15 minute session where you highlight your facility’s CDI program. A brief power point is useful in showing these physicians key reasons for why the CDI program is important. Highlight how documentation impacts statistical data on risk of mortality, reflection of severity of illness, length of stay (LOS), quality core measures, accuracy of the medical record, and Case Mix Index—inclusive of resource consumption and revenue capture. A key point I often make to physicians is the example with length of stay. By accurately reflecting how sick their patients are it can help facilitate justifying the increased length of stay and in the Medicare population if the patient is in the hospital for three midnights providing support for nursing home resource consumption if it is needed.

In addition, the power point should provide examples of documentation scenarios that show diagnosis related group (DRG) improvement after proper documentation is provided. Physicians are often visually impacted by seeing how things will improve. The example should include the case’s DRG baseline relative weight, length of stay, severity of illness and risk of mortality impact after additional clinically supported diagnoses are added. On top of the new physician orientation education, a CDI professional should come to periodic physician staff/division meetings. At these meetings, it is important to provide education on a key topic that the facility sees as needing further physician specificity. For example, congestive heart failure requires further detail on type and acuity.

The other key component to a successful CDI program is being visible and available to physicians. When a CDI professional is on a nursing unit reviewing a health record and interacting with physicians and the rest of the ancillary team, it helps to establish a team approach. Physicians see that you are available, friendly, and often appreciate real-time conversations for documentation queries instead of additional mail or paperwork to fill out.

In conclusion, the overall goal is to accurately reflect how sick your patients are. Patients depend on a complete and accurate medical record. If these patients go to another facility, the picture that is painted at your facility for their care may be imperative in ensuring a positive outcome at another.

 

Jennifer A. Daly is a clinical documentation specialist at Advocate Good Shepherd Hospital.

1 Comment

  1. What a well drafted summary of an effective CDI program, truly identifying the importance of the presence of the team and the value of consistent teaching and probably repetitive communication with physicians

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