Health Information Management

Q&A: Extending CDI education beyond physician-only documentation

CDI Strategies, August 20, 2015

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Q: Our CDI specialists will present to our inpatient rehabilitation department (including physical, occupational, and speech therapists). We’re thinking about providing a general introduction to CDI outlining what it is, who we are, and the goals of our department. And, of course, we’d like to address documentation specific to their department. 

We will most likely mention that although we cannot code based on their notes, it is helpful if they document specific words, so in the event we need to query the physicians, we can use their notes to support the query.

Do you think this is a good idea? Do you have any other suggestions regarding documentation that we should include for this group?

A: Many people state the education function of a CDI specialist is to teach the physicians about the needs for quality documentation. I do agree that the physicians are our primary focus but I define our education responsibilities a bit differently. I feel it is our responsibility to educate everyone who documents in the chart. I called it my “CDI Roadshow.”

I agree that you need to start with a basics. Definitely explain why documentation is so important and how it influences your organization’s health to include both direct and indirect reimbursement, and reputation related to publicly reported quality data.

For the rehabilitation department, I think your focus is spot on. Encourage them to describe patient function, the presence of hemiparesis, and any other neuromuscular deficits. Remind them to describe whether the patient is at risk of falls and if there are any anomalies related to gait. Documentation of aspiration and swallow evaluation is also an important target area. If your rehabilitation department is involved with wound care this may be an area of needed education.

Let them know you read their notes and how they are helpful to you. I once had a dietician say to me, “You read my notes? I didn’t think anyone read my notes!”

Good luck and please let me know how it goes.   

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.



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