A physician’s focus primarily has been the care of the patient, with time allowed to clarify their working or discharge diagnosis and maintaining their patients in the hospital setting. That’s where a clinical documentation specialist (CDS) comes in. At Civista Medical Center in Maryland, color-coded worksheets are printed and attached to the patient’s medical record. The purpose of the worksheet is to trigger the physician to write specific documentation.
Education! Education! It cannot be stressed enough. Healthcare is a team effort. To achieve accurate and concise documentation, physicians must be educated about the importance of documentation. Nonspecific documentation leads to nonspecific coding of the medical record. Therefore, the true severity of illness, mortality rate, and intensity of service goes uncaptured. The lack of specificity in documentation affects the quality of patient care, compliance risk, data integrity, and reimbursement.
The implementation of a CDI program can be successful by enlisting internal support at your facility, including administration, physicians, and such ancillary staff members as case management. A clear, concise plan that includes physicians every step of the way will be imperative.
Consider the many avenues you might have to implement your query system, either by paper or electronically. If the coding department does not own the concurrent CDI query process, make sure they are involved in the process of establishing the program. In addition, provide feedback to various facility departments about the impact the CDI program is having on quality, integrity, and reimbursement. Include an ongoing program to educate the physicians on ICD 9-CM, as well as the forthcoming ICD 10, for a smoother transition.
Karen Stanley, RN, MBA,
White Plains, Md.