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Use CDI tools effectively

HIM Connection, February 10, 2004

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The adage, "if all you have is a hammer, every problem looks like a nail," applies well to clinical documentation improvement (CDI) program and tool development. Documentation tools can enhance any CDI program by pushing staff to better document their work and their patients' conditions. But the tools you use should be versatile and able to meet every possible challenge that physicians, nonphysician clinicians, or other staff may face.

Although generic tools designed to work for many providers might seem like a good option, your CDI program is more likely to succeed with custom-designed tools. Use tools that define specific pieces, as well as general concepts in your CDI program. They should adapt to fit your organization and be flexible enough for users get the most out of them.

The following CDI tools could help your staff build better documentation:

• Laminated pocket cards with documentation guidelines
• Templates for history and physical (H&P) exams, progress notes, and other forms
• Books, either off the shelf or custom designed
• Query forms
• Software
• Reminders, either posted on the wall or in a patient's record
• Videos
• Web-based learning

Don't forget, designing the right tools is only one part of a CDI program. You shouldn't rely on tools at the expense of physician and clinician interaction and cooperation--doing so could cripple your CDI program.

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