The establishment and enhancement of a CDI program at Bronx-Lebanon Hospital Center originated in 2010. Robert Leviton, MD, the hospital’s chief medical information officer/physician advisor, Diane Johnson, director of HIM, and Mohammad Ahmed, MD, assistant director of CDI believed that an electronic medical record system’s integration with patient care, documentation, and revenue cycle management would be beneficial to all stakeholders.
“CDI will become even more significant in light of ICD-10, by providing a proven practice work flow that captures clinical documentation, provides enhanced opportunities for improvements, and permits billing that is increasingly dependent on the ability to code correctly,” Johnson said.
All Bronx-Lebanon Hospital CDI specialists are physicians who hold coding credentials from AHIMA, which makes its CDI program distinct from other programs. The trend of hiring foreign medical graduates or physicians at other institutes is also growing, due to enhanced CDI query response and agreement rates.
“As physicians, we have tremendous insight into the thoughts of the clinical staff, including detailed assessments relativity to the documentation needs,” Ahmed said.
The CDI program at Bronx-Lebanon started with the implementation of Allscripts Care Manager Program, as well as 3M Encoder and reference. “Our CDI query and response rate is outstanding, since CDI staff place queries based on medical evidence and clinically significant conditions,” said Ahmed. CDI staff collaborate and provide accurate coding opportunities for the HIM and case management department by posting geometric mean length of stay on the patient’s electronic facility board.
Through concurrent review of a patient chart and after computing the initial DRG into Allscripts, CDI specialists enter principal and secondary diagnosis along with the procedures. Concurrent queries are directed verbally, as well as electronically. CDI staff continues to review the charts until the patient is discharged to ensure all necessary information is captured. The CDI staff also takes on a vital role in facilitating retrospective queries with collaboration of HIM coding mangers.
The DRG status in Allscripts is specified by DRG icon color. A blue colored DRG icon indicates that the patient chart is not reviewed by the CDI, whereas an orange DRG icon indicates that the chart review is in progress or waiting for final DRG. When a physician documents additional diagnoses or clarifies documentation in the patient’s medical record, the CDI specialist captures these changes and assign a working DRG by updating diagnostic codes, as well as electronically posting the expected length of stay (LOS) on the electronic facility board, thereby providing guidance to the clinical staff regarding the remaining LOS. The final DRG and codes are assigned by HIM coders for all discharged cases. A working and final DRG matching situation is indicated by a green DRG icon color, whereas the red DRG icon color draws attention to a discrepancy in coding data, either by the CDI or HIM coder. These charts are then reassigned to the HIM manager to reconcile the data.
“Our discrepancy rate is very low, an indicator of the program’s success,” said Ahmed.
Another key metric of the program’s success is its reporting structure, CDI program productivity reports are presented to the hospital’s chief medical information officer on a regular basis. Using the electronic format allows the CDI staff to be transparent. This practice enhances the coder’s efficiency and also opens an opportunity for educational dialogue between HIM coders and CDI staff. Numerous tools to help physicians learn about the importance of better documentation and update them about Centers for Medicare and Medicaid Services (CMS) and Joint Commission on Accreditation of Healthcare Organization (JCAHO) guidelines are also provided.
“Our CDI team at is not only hardworking and dedicated, but their unending efforts continue to serve as a model for CDI programs throughout the nation,” Ahmed said.
By Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA
- In-depth knowledge of ICD-9-CM guidelines and conventions
- Access to and awareness of pertinent AHA Coding Clinic references
- Understanding of the MS-DRG reimbursement system, including relevant MCCs and CCs that affect the MS-DRG assignment
- Clinical Documentation Improvement Practitioner (CDIP)
- Clinical Documentation Specialist (CCDS)
- Registered Health Information Administrator (RHIA)
- Registered Health Information Technician (RHIT)
- Certified Coding Specialist (CCS)
Editor’s Note: This post is part of an ongoing series of Q&As with presenters and participants from the 2012 ACDIS Conference in San Diego. The following features Jennifer Love, RN, BA, CCDS, and her co-presenter Janet Gentle, RN, BSN, MSN, CCDS on the presentation “CDI Career Ladder: Two Perspectives,” which takes place today, Thursday, May 10, 3:15-4:15 p.m.
Q: How long have you been a CDI professional?
JL: In 2008 I was hired as the manager of CDI for Novant Health. In 2011, I became the area director of Clinical Documentation Improvement for Kindred Healthcare.
JG: Seven years.
Q: What inspired you to follow this career path?
JL: When I was a Surgical Care Improvement Project analyst at Novant, my senior director informed me that the hospital system was considering implementing a CDI program. In discussions that followed, I was allowed to purchase The Clinical Documentation Improvement Specialist’s Handbook. I read that book cover-to-cover! I was hooked! CDI was something fresh; a new challenge which definitely sparked my interest. I was hired as the manager of Clinical Documentation Improvement and the CDI program was implemented shortly thereafter.
JG: We had consultants who were brought in to redesign our case management (CM) department and establish a CDI program. They encouraged me to interview for the dual CM supervisor/CDI position which, within three years, turned into a full-time CDI position.
Q: What should someone who is interested in becoming a CDI specialist do to begin their career?
JL: I’d recommend they read The Clinical Documentation Improvement Specialist’s Handbook, too, or check out the ACDIS website before making the leap. I would also encourage them to get approval to shadow current CDI specialists.
To take the CDI career path, the individual should be very attentive to detail, e computer savvy, and possess clinical expertise. To take on this career, the individual will be required to communicate effectively to everyone from coders to physicians. I’d also tell them to be honest with themselves regarding their weakness and strengths. If the CDI role plays up your strengths—go for it! I wish you the best of luck! Give yourself time to master this role, however. It will take months before you will feel truly competent. One more thing, you will make mistakes. No one in this field is perfect.
JG: Definitely research the CDI role first. And take part in ACDIS/AHIMA educational opportunities. In fact, join ACDIS/AHIMA on either the national or local level for educational and networking opportunities. Attend conferences/educational programs such as Boot Camps and look for an entry level position with a facility that will help train you.
Of course someone looking to advance their CDI career should be able to research best practices to improve current processes, know how to monitor effectiveness via internal audit/productivity measures, understand the importance of developing policies and procedures. There are other ways to advance your career, too. Those on the cutting edge of this profession know how to develop ICD-10 compliant queries or have become involved in their local ACDIS chapter.
Additional opportunities exist down some unexpected avenues such as CDI travel assignments and remote CDI at home, etc.
Q: If a CDI professional has been working in the field for a few years what steps should they take to advance their role, program, and/or career?
JL: Don’t let yourself stagnate. Always be reading something or pursuing something for your professional growth. Don’t rely solely on your employer to sign you up for conferences, classes, etc. Take the initiative yourself and your employer will take notice. Also, if you are interested in an opportunity for advancement—speak up! Your boss can’t read your mind. Once you’ve shared your interest, your boss then starts ‘grooming you’ for the next big thing. You never know!
JG: Develop a CDI team leader/coordinator position and consider yearly salary market adjustments in addition to raises. Look for reimbursement for conference attendance and tie that attendance to team education and CDI program process improvements. There are increasingly opportunities in collaborative environment and autonomous practice
Q: What steps can a CDI manager take to help staff members feel there are opportunities for advancement at their own facility?
JL: One thought is to implement a CDI career ladder program. Another thought is to encourage the employees to build relationships with quality, HIM, case management, and other related departments within the facility as opportunities for advancement may exist and/or open up in one of them. The specialized experience of a CDI professional along with the other skills one possesses would make for an appropriate transition during a needed time of new projects, etc.
JG: As mentioned earlier managers need to provide different educational opportunities and tie those opportunities to overall process improvements within the program. Empowering staff to take ownership of their own career is also important.
Q: What are you looking forward to most at this year’s ACDIS conference?
JL: I look forward to seeing the beautiful city of San Diego, those familiar smiling faces, and taking away at least one pearl of wisdom that will take me to the next level of CDI expertise.
JG: Presenting about career ladders! I am also looking forward to all the networking opportunities the great educational opportunities. Our local chapter the Michigan ACDIS is having dinner together on Wednesday night and then Friday I’m looking forward to the great Local Chapter Networking Lunch and Event. Of course, I’m looking forward to the sunshine and visiting the Pacific Ocean.
Q: What inspired you to become an ACDIS conference speaker?
JL: I felt compelled to share valuable insight from my recent CDI career change with my ACDIS colleagues. I wanted others who may be considering a CDI job change to be even more equipped and informed than I was during my job search.
JG: I am very passionate about creating a career ladder for nurses in alternative practices, such as CDI. Historically, clinical ladders have been developed for bedside nurses. The development of the specialty ladder at Northern Michigan Regional Hospital was innovative and based on original literature search, and it has afforded all NMRH nurses equity and opportunity for professional advancement.
What new boundaries are CDI professionals exploring? CDI specialists discussed several areas of expansion during the 2011 CDI Week celebrations last September. You can read about them in the special CDI Week Q&As and in the CDI Week Industry Survey, which are still available on the ACDIS website. CDI professionals also frequently explore the boundaries of the CDI profession on the ACDIS Blog and on CDI Talk discussion strings.
And I know that those fortunate enough to attend the ACDIS conference in San Diego next week will certainly learn about new documentation improvement opportunities. Come to think of it, the conference has such good ideas every year—and a good idea doesn’t truly get stale—you should take a look back at conference materials from previous events to see what tips you may find and consider implementing.
Conversations regarding CDI expansion really should be considered aspects of program and organizational strategic planning. CDI managers need to consider where CDI specialists will focus their primary efforts over the next year, two years, even five years.
Yes, the regulatory environment governing healthcare is always changing and most CDI program directors can guess about how those regulatory changes will affect CDI, patient care, and the healthcare revenue cycle. But well-informed professionals can make some practical suggestions to position their CDI team appropriately for the future.
Warning, what follows is somewhat like throwing pasta against a wall—some ideas may simply fall and other ideas, like a good al dente macaroni will stick. Regardless, here are my thoughts about possible avenues for CDI program expansion.
CDI specialists should consider conducting record reviews for:
- Mortality/quality/length of stay/severity of illness profiling
- Surgical complications
- Hospital acquired and present on admission conditions
- Medical necessity support (both initial and ongoing stay)
- Evaluation and management documentation
Additionally, CDI programs may gain ground by exploring:
- Medicaid, third-party, private payer initiatives
- Outpatient CDI (e.g., emergency department, ambulatory, denials management)
- Documentation improvement opportunities in alternative settings such as long-term care, rehabilitation, psych, pediatric, and obstetrics units (ACDIS recently launched a new networking group dubbed APDIS-the Association for Pediatric Documentation Improvement Specialists)
- New government initiatives such as Value-Based Purchasing, Accountable Care Organizations, and payment bundling
- Proactive Recovery Auditor and external auditor defense
- Collaboration in development of clinical best practice, documentation, protocols, etc.
- Data mining and reporting (internal drivers and external reports)
- ‘Hardwire’ documentation improvement elements in EMR and IT systems
- Quality data versus coded data
- Why and where does a difference exist?
- What can be done to ensure both data sets are parallel and completely accurate?
- How can CDI contribute to clinical care and quality data measurements?
Of course, a number of previous posts directly or indirectly address exploring new CDI areas. As you investigate new ideas, try new things out, consider sharing with your professional colleagues—comment on CDI Talk, write a blog post, contribute a CDI Strategies quick note, or partner with other staff to write a CDI Journal article.
Although you might not have heard of it before, ACDIS has formed a group called the CDI Roadmap Committee to help develop and define some of the core structures that the CDI profession has been lacking. These include the broad goals and objectives of CDI, staffing and productivity considerations, setting new goals for mature programs, and a realistic structured outline to help map out the way.
The CDI Roadmap Committee has been meeting since September 2011. The committee currently consists of the following members:
- Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, ACDIS Advisory Board Member, Independent Revenue Cycle Consultant in Madison, WI.
- Lynne Spryszak, RN, CCDS, CPC-A, ACDIS Advisory Board Member and independent HIM consultant in Roselle, IL.
- Donna D. Wilson, RHIA, CCS, CCDS, ACDIS Advisory Board Member and Senior Director of Compliance Concepts, Inc. in Wexford, PA.
- Cheryl Ericson, MS, RN, ACDIS Advisory Board Member and CDI manager for Medical University of South in Charleston, SC.
- Gail B. Marini, RN, MM, CCS, LNC, ACDIS Advisory Board Member and CDI manager for South Shore Hospital in Weymouth, MA.
- Beth Kennedy, RN, BS, CCS, CCDS, Associate Director, Documentation Improvement Program CMO, The Care Management Company, LLC., Montefiore Medical Center in Bronx, NY.
The majority of the group’s first meeting was spent discussing the purpose and intent of the group and defining both short and long-term objectives. The committee determined that its objective is to create a phased approach to CDI success. The team decided to develop a pre-implementation timeline/checklist, then took a deeper delve into the goals/objectives of a basic CDI program and requirements and expectations for staff.
At subsequent meetings members offered drafts of a pre- implementation checklist with items such as assembling a steering committee and an outline for developing a project plan. The group also discussed sample orientation checklists, collected job descriptions for physician advisors, CDI supervisors, and CDI specialists, and discussed potential CDI evaluation criteria and assessment of CDI staff coding and clinical skills.
The CDI Roadmap Committee will likely break after it completes the “pre-implementation” and “implementation” phases of the timeline, and continue work on “ongoing maintenance” and “advanced level CDI” phases at a later date.
The committee plans to send its work to the ACDIS advisory board for approval and compile its findings in a series of White Papers available as free resources to the ACDIS membership.
Editor’s Note: This article first appeared in the March 15 edition of CDI Strategies.
This is the time of year for CDI specialists to evaluate their programs and set goals for the coming year. What are your goals?
Beware of setting unrealistic or lofty expectations. Everyone would like to make three million dollars, and raise their facility’s case-mix index by two points but are you setting yourself up for failure. Perhaps you can start with capturing better specificity for patients admitted with CHF.
Set your own personal goals, such as becoming more active in your local ACDIS group, or requesting to attend the National ACDIS Conference. You may want to get your CCDS certification, or write an article for the ACDIS Blog. Your goals can be as simple as creating a poster for the doctors’ dictation area.
Write your goals down and then periodically look at the list and strive to attain the items listed. This list may also be used later for your yearly evaluation, to serve as a reminder to others of your achievements. It doesn’t hurt to toot your own horn periodically.
Set program goals as well. This may constitute a review of policies and procedures or the formulation of a Recovery Audit Contractor pre- audit group. And, it is not too early to start getting ready for ICD-10. (Actually, you should already be getting ready, but that is a different topic.)
Take a few minutes at the end of the day and jot down a few ideas. These seeds for thought may take full bloom come the springtime.
So with this in mind, have a wonderful holiday and a fantastic new year!!
A recent discussion on the ACDIS CDI Talk list serve provoked me to ponder: Is your program truly an asset
to your organization? Does it promote complete and accurate clinical documentation reflective of patient severity of illness (SOI), medical complexity and quality outcomes that justify the costs of care? Or is your program really a liability to the organization?
The CDI Talk discussion asked how programs calculate their return on investment (ROI). One response pointed out that any monthly report of CDI case mix change and financial reimbursement effectiveness must include a disclaimer informing readers about the fact that such data is subject to adjustment for transfer DRGs provisions inherent in the inpatient prospective payment system (IPPS). So, here’s my two-cents on the issues raised.
Another adjustment to consider
An effective CDI program can be a significant asset or a significant liability depending upon how the program is initially structured, set up, rolled out, and carried forward with daily CDI activity. Unfortunately, a majority of CDI programs center their metrics (proof of their ROI) on increased financial reimbursement to the hospital. This takes away from the overall potential of the CDI program for the hospital as well as the physicians. That’s because this narrow focus on reimbursement positions CDI programs as revenue enhancement programs. It forces CDI specialists to focus on the capture of CCs/MCCs and “more specific” principal diagnosis. And this, in turn increases risk and liability for the hospital.
Consider the following common analysis conducted by CDI programs to prove their effectiveness:
- Number of queries left by the CDI
- Number of queries that change the principal diagnosis
- Number of queries that add a CC/MCC
- Number of physician queries responded positively to by the physician
- Number of physician queries not responded to by the physician
- Number of queries left in the record which the physician did not agree to clarify/add documentation
- Potential capture rate of monthly CC/MCC not obtained due to physician disagreement
- Change in monthly case-mix-index
- Time from admission until record was reviewed and DRG worksheet completed
- Average number of times a record was reviewed per admission
While reviewing these statistics can provide insight into a CDI program’s success, commitment to these types of matrices as the sole indicators of a program’s success can stymie a program.
A primary goal of CDI professionals is to improve overall clinical documentation in the record for purposes of accurate, concise, and effective reporting of patient acuity/SOI, physician clinical judgment, medical decision making, and resource consumption through specificity in documented diagnoses.
One of many “by-products” of this stated goal of CDI is that the resulting reimbursement more closely approximates the care provided. However, strict focus on financial reimbursement benchmarks creates incentives for staff to omit queries that don’t affect payment or increase queries for conditions that do. This, ultimately, artificially creates a rosy ROI picture for the CDI program. It also increases financial risks as auditors data mine, down-code, deny, and ultimately take back reimbursement from erroneously documented and coded cases.
Now you see it, now you don’t
In my experience, many a RAC denial is fundamentally related to CDI program deficiencies. Often a query results in the physician documenting a diagnosis in the record just once. The query may have asked the physician to clarify the principal diagnosis, secondary diagnosis, or sought to add a CC/MCC to the record.
These queries frequently include:
- Aspiration vs. community acquired pneumonia
- Sepsis with change in mental status vs. sepsis with acute encephalopathy
- COPD exacerbation with hypoxemia vs. COPD exacerbation with acute-on-chronic respiratory failure
The physician may respond to the query by including the specified diagnosis or diagnoses in his/her next progress note yet not include these same diagnosis specificity in the continued care progress notes and discharge summary. According to our previously discuss benchmarks, the CDI manager counts the physician’s response as a “win,” and moves on to the next chart review.
The physician’s conclusory diagnostic statement without accompanied discussion of pertinent clinical facts and information constitutes insufficient documentation from an “outsider’s review” perspective. The RAC or other third-party payer retrospective reviews frequently down-code or deny these claims due to such documentation deficiency.
Effective CDI programs should incorporate more than financial measures in their program benchmarking. Clinical documentation beyond mere diagnostic conclusory statements supporting clinical presentation of the patient as well as the clinical facts of the case is essential for revenue integrity and continuity of care. Consider the following found in the most recent Statement of Work for the RAC:
“Clinical validation is a separate process, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented. Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder.”
Now is an ideal time to consider your answer to the “asset vs. liability” dilemma, take inventory of the processes of your CDI program, and aim for positive process changes in the new year to ensure your program’s contribution to the healthcare organization.
One may wish to determine how many RAC denials were associated with disallowance of principal or secondary diagnoses (CC/MCC) on the basis of insufficient documentation. The continued success of the profession of CDI is predicated upon adapting to changes in the healthcare marketplace. Renewed emphasis on a “visionary” mindset versus complacency will ultimately govern the true success of your CDI program.
When writing last week’s post “Voices & Perspectives,” I starting thinking about all the different ACDIS Blog posts I’ve enjoyed reading over the years.
The ACDIS Blog has been active since March 2008, and there are a good number of visitors, many of whom I suspect read it regularly and certainly not all of whom are ACDIS members. This causes me to wonder, what are readers’ favorite posts?
I want to ask this question from several perspectives.
- What are your favorite types of posts?
- Industry news:
- Information and analysis about at is happening with CMS, RAC, MIC, quality, industry trends, OIG, etc.
- News of changes to ICD-9 codes, Coding Clinic for ICD-9-CM, MS-DRGs, etc.
- Information regarding consulting and vendor services
- ICD-10 implementation news and tips
- Information regarding other industry associations such as AHIMA and ACMA
- ACDIS announcements regarding:
- The annual conference
- Local chapter meetings
- ACDIS growth and development
- Publications and webinar announcements
- Advocacy efforts
- “Introductions” to ACDIS staff and board members
- The annual conference
- Case studies from CDI professionals regarding:
- Clinical/disease topics
- Physician relationships
- CDI process and policy development
- Book excerpts
- Posts from ACDIS’ sister publications such as JustCoding.com or Case Management Monthly
- Q&A from membership
- Resources and references
- Fun topics like cartoons or holiday theme
- Industry news:
- Which individual posts really stand out in your mind?
- Which posts do you most frequently reference back to?
- Who do you like to hear from the most? Is there anyone else you’d like to hear from?
- ACDIS staff
- Experts within the CDI and related professions
- “Regular individuals” CDI specialists, local chapter leaders, CDI managers
- A specific presenter from a local or national conference?
- An author of a book or webinar?
- Experts from related areas within HCPro?
- A guest from another professional organization?
- Directly from a consulting or service company?
- An academic individual?
- CDI Advisors?
- Clinical experts?
So, let’s hear your thoughts and requests! Don’t forget to ‘nominate’ specific individuals!!
I see strong evidence that ACDIS is involved with the broad project of defining and expanding effectiveclinical documentation improvement (CDI) practice. For our association to thrive in this endeavor, however, a chorus of voices and perspectives from the CDI community are needed.
In the course of this discussion we must actively maintain a communal understanding of what CDI encompasses. We must continuously ask each other:
- What do CDI specialists do that sets them apart?
- What kinds of activities identify a CDI staff member?
- What knowledge, skills, and abilities do the majority of practicing CDI professionals demonstrate?
- What are the characteristics of strong CDI programs?
To keep our profession (and our professional organization) strong, we need to participate in respectful, professional debate. We need to foster discussions surrounding philosophy, growth, ethics, new projects, and/or fundamental focus areas not just for ACDIS as an organization but for all of us working in the industry. Through this dialogue we will be able to find additional ways to effectively promote the fundamental aspects of CDI, to continue to grow and adapt professionally.
I believe ACDIS offers great resources toward fostering this discussion including:
- The quarterly online publication CDI Journal
- Benchmarking surveys with expert analysis and commentary
- Annual conference
- State networking chapters
- The ACDIS Blog
- CDI Talk
This blog and CDI Talk are two outstanding venues that I feel are particular venues which promote fast, interactive conversations.
I absolutely love reading the ACDIS Blog. I find the posts informative, thought provoking, reflective, introspective, and challenging. I expect (and consistently observe) well written and cogently argued viewpoints. In my opinion, the ACDIS Blog provides:
- Important news items that highlight information, events, activities, or resources that all practicing CDI specialists ought to know and understand
- A venue for the expression of individual thoughts and concerns by those with enough courage to explore and share what they feel to be the heart and soul of a CDI professional’s life
- An arena where we, as CDI professionals, can truly look forward to what the future of CDI might be
- Thought provoking content which challenges us (and allows us to challenge others) to uphold the highest expectations for ethical behavior
- A wonderful group of posts that entertain and delight, which bring a smile and a laugh when we need it the most.
I’ve found inspiration along with practical tips from shared individual experiences on the ACDIS Blog. And I’ve found that the discussions about challenges we all face have provided me with support, encouragement, and new strategies for growth that I have been able to implement in my own program. What’s more, the content on the ACDIS Blog is free, open to any interested professional.
Though the blog is important, the CDI Talk listserv forum which is available to ACDIS members provides a faster method for CDI specialists to reach out, ask a question, and be assured of responses. CDI Talk offers smaller bits and pieces of the more formalized discussions found on the blog, as well as all of the opportunity for individual interactions and questions. It is really is a fun community to belong to.
To me, the growth of our CDI profession and of its professional association, ACDIS, often feels like a process of discovery. Our profession will only continue to improve as long as we listen, reflect, and discuss the viewpoints everyone offers. I encourage everyone to discover their own interesting, exciting or passionate topic and write an original blog post, or start a CDI Talk conversation.
I’d love to see broad participation from everyone in these conversations and explorations. Thank you to the wonderful folks who currently contribute! A vision for CDI that includes professional growth and development needs a great variety and wealth of participation, of voices and perspectives, so please, join the conversation.
I feel like saying a little bit about why we do what we do, or at least why I do what I do. In the course of my 26-year nursing career, I worked in many venues. For about 14 years, I was an ICU nurse, and although many patients have merged in my memory, there are those whose memory will always remain as fresh as yesterday. Somehow, I seem to remember everything about these chosen few, as if they had been painted in my mind.
I no longer provide direct patient care. In fact, these days I rarely see a patient in the flesh. Yet, every day I come to know anywhere from 40 to 90 individuals who come to the hospital in varying states of health. I know them through their charts. I know them because I am a clinical documentation specialist.
For me to do my job effectively, I must insure that the artists—the bedside caregivers—paint the most strikingly vivid picture possible of each and every one of these unique individuals.
When I read their charts, I visualize that patient in the bed. I see them complete with a face and a body. I see family members, monitors, tubes, medications. I see the physicians establishing—and sometimes struggling with—the big picture, and I see the nurses working as they provide hands-on care.
I read about the 32-year-old new mother with metastatic cancer and I feel her worry and her pain. I read about the noncompliant dialysis patient on his 10th admission for fluid overload and wonder what conditions could possibly lead to inpatient hospitalization being preferable to outpatient compliance. I read about the 90-year-old woman with a lump on her breast and I know she’s been agonizing over whether a mastectomy is worth it.
I see symptoms and I anticipate diagnoses. I see diagnoses and anticipate procedures. I see procedures and anticipate paths to recovery. Clinical documentation improvement is about making sure that the words match the reality. I need the physicians and nurses to write exactly what they see, what they think, and what they do. And I need them to say it in a way that satisfies government and managed care regulators.
Sometimes, I think of physician documentation in the context of the Blind Men and the Elephant. The Blind
Men and the Elephant is an old tale from India in which six blind men each take hold of a different body part, unaware that they are touching an elephant. One man touches the tail and thinks it is a rope; another grasps the trunk and thinks it is a tree branch; a third thinks the tusk is a solid pipe, and so on. The reality is that they are all right and they are all wrong; it’s a matter of perspective.
As clinical documentation improvement specialists, we take the findings of the nephrologist and the cardiologist and the surgeon and the internist and we try to bring them together to understand the health concerns of the whole person so that everyone can recognize them. When we only see evidence of a tree branch or a rope instead of an elephant, we intervene.
When I was a nursing instructor, I used to tell my students that their path to becoming a nurse was not linearly following a series of tasks, but rather, slowly solving a complex jigsaw puzzle. Every new experience allowed them to add another piece, but the pieces might not be found in the order in which they looked for them. In time, though, one should eventually have a vision of the nurse taking shape, and fewer white spots on the table.
So it is with patients. A patient comes in with a vague complaint, and they expect the doctor to make a diagnosis. In the current status of healthcare’s revolving door, the physician has less and less time to make those determinations; determinations which nevertheless must be made. At times, a physician resists writing a possible diagnosis for fear of being wrong. I encourage doctors not to fear the diagnosis. A differential diagnosis, honestly considered, does not hurt either the patient or the physician. It merely shows the level of effort expended by the physician and the healthcare team in trying to solve the puzzle, and often that effort will be rewarded with greater severity of illness scores and perhaps even higher reimbursement.
I will help the physician understand how to write the diagnosis in a compliant manner that protects the patient, the physician, and the hospital.
The portrait has to be painted with some consistency. When one physician writes, “CHF,” while another writes, “pulmonary edema,” and a third writes, “fluid overload,” regarding the same set of symptoms experienced by the same patient, it’s the equivalent of three artists each trying to paint a perfectly pink dress with three different tubes of paint. One uses red paint, one uses white paint, and one uses orange paint. Without working together, none of them gets the color quite right. In the end, sometimes it isn’t even clear that the painting is of a woman in a dress, much less a woman wearing pink.
So, I help hand them the right paint, explain about the various rules of shading and perspective. In this metaphor I give them the right paint brush to use, offer up the appropriate words—acute systolic heart failure—and let them add it to their paintboxes. With the correct verbiage, everyone reading that chart, not only the regulators, sees the woman in her pink dress, sees the patient with acute systolic heart failure, and understands the diagnosis.
Nurses like to talk about the art and science of nursing. There is much science in the clinical documentation improvement role, but a lot of art, too.