Topic: Consider these pointers when rolling out a clinical documentation improvement educational session
HIM Connection, September 16, 2008
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When rolling out a documentation improvement education plan, perform a baseline assessment to determine where your plan should begin. You will most likely need to begin by defining basic coding principles and definitions, such as principal diagnosis, secondary conditions, complication/comorbidity (CC), major CC, and case-mix index.
The clinical team should receive an overview of compliance expectations, as well as an overview of what to expect from a query. Use feedback from the patient care team to determine the content of future training sessions. It is helpful to frame training sessions in terms of specific specialties. For example, one training session might involve discussing how MS-DRGs affect cardiology. Consider the following pointers to make sessions most productive:
- Agree on a set length of time for the session. Do not let the session run past the allotted time.
- Advocate for shorter sessions that take place on a regular basis. Consider scheduling sessions during breakfast or lunch breaks.
- Be organized and concise.
- Provide real-life examples, using de-identified patient records.
- Engage attendees in questions and answers.
- Don’t bluff if you don’t know an answer. Let attendees know that you will get back to them in a reasonable amount of time. Remember to follow through, or you may lose credibility.
- Share data, such as benchmarking or progress reports.
- Highlight the program’s successes. For example, how have MS-DRGs affected the severity of illness or risk of mortality for a particular service line? How has a particular physician champion helped change documentation patterns?
- Recognize individual physicians’ efforts. Remember to thank physicians for their support and participation.
- Provide summaries or pocket guides with clear take-away points that attendees can implement.
- Reinforce the continued need for CDI specialists to participate in team rounds to sustain results.
- Follow up with each individual attendee, and thank all attendees for their time.
- Ask for feedback on the content of the presentation, and strive to implement any recommendations.
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