by Steven Robinson, RN
Most physicians want to provide an accurate written picture of their patients, and many believe that they document effectively and consistently. However, when queried by a CDI specialist, physicians often require help to understand exactly what needs to be further explained in their documentation and why.
There are many ways to address and educate physicians about documentation best practices. They include:
- Grand rounds. You can build credibility by discussing specific cases from a CDI perspective while making rounds with the physician. CDI staff can explain how specific documentation can help justify resources, demonstrate a higher SOI/ROM, and improve patient care.
- Posters. Visual posters on performance can grab a physician’s attention. Display a poster in the nurses’ or physicians’ lounge describing documentation for specific diagnoses that frequently creates challenges for your physicians.
- Group meetings. Schedule data report presentations for physician sub-sectional meetings that demonstrate successes and challenges (physician names are usually omitted in these presentations). Physicians tend to respond positively to clearly illustrated trends.
Remember that it is always necessary to offer physicians education on documentation compliance. CDI specialists should support physicians by providing queries as needed and by continually making them aware of changing rules and regulations regarding documentation compliance.
Editor’s note:In the April 2010 edition of the
CDI Journal, Maxim Health Information Services began a year-long series of sponsored articles to examine some of the top trouble spots of CDI implementation. Learn more about opportunities for CDI process improvement from
Maxim Health Information Services.
