Health Information Management

Stress synergy and collaboration to make your CDI program work

CDI Strategies, March 5, 2009

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CDI professionals should not only work with physicians to clarify documentation, but should involve all clinical ancillary staff as well, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI, senior coding and chargemaster consultant with QHR in Brentwood, TN.
“Everyone has a role in this (CDI process),” he says. “Expand the concept of documentation and make it everyone’s responsibility.”
CDI specialists should provide presentations for groups like ED nurses, wound therapists, nutritionists, and laboratory and radiology staff on initiatives like the Recovery Audit Contractor (RAC) program, and on general concepts like medical necessity. If they understand how appropriate documentation supports these concepts and initiatives, then clinical staff members can themselves prompt physicians for diagnoses, Krauss says. For example, if a physician orders a blood transfusion a nurse may appropriately ask the physician for the appropriate diagnosis (acute blood loss anemia, for example).
“It’s not more work—the nurse is already calling the doctor for a plan of care change, and the bottom line is they just need the physician to put their thought processes on paper in a sentence or two,” Krauss says. “They’ve already asked the question.”
Good nursing notes can also be used to combat denials, which is another point to stress to clinical staff members to get them involved in CDI efforts, Krauss says. For example, a nurse wrote in a medical record: “Patient saturation 72% upon arrival in ED, put oxygen on.” The nurse told Krauss she gave the patient oxygen after she called the physician, who then instructed her to do so. If the nurse wrote why the physician instructed the use of oxygen the facility could then use this note to defend a denial for acute respiratory failure.
CDI specialists should view documentation as a manufacturing process from the time the patient is admitted until the time of discharge, Krauss says, with the CDI specialist as quality control manager.
“Everyone has a vested interest in producing documentation, not just the quality control people at the end,” he says. “It (good documentation) promotes the value of what all these groups are doing.”

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