Health Information Management

Tool: Documentation certificate aids physician education

CDI Strategies, January 7, 2010

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Susan Borrego, MSN, RN, CCDS, and Michelle Limo, MSMIT, RN, CCDS represent the two-person team that is the Salinas Valley Memorial Healthcare (SVMH) system’s CDI department. The public district hospital in the Salinas Valley of Central California is a 269 bed acute care hospital with multiple specialties including a regional heart, spine, cancer, women and children’s programs, a Level III neonatal ICU, and an emergency department. SVMH employs 2,200 people and the medical staff includes 265 board certified physicians across the specialties. 
Borrego and Limo review all inpatient Medicare charts, about 350 per month, and on average about 16 new patient charts per day, Monday through Friday. How does this dynamic duo do it?
Well, they are both registered nurses with masters’ degrees, and both earned their Certified Clinical Documentation Specialist (CCDS) credential in May 2009. To help get their physicians on board with the CDI program, the facility brought Esklid A. Peterson, MD, from 3M, in to offer a presentation to its medical and leadership and board members, in November 2009. Borrego says that Peterson’s presentation “Sustaining Clinical and Financial Performance” included:
  • information regarding the importance of clinical documentation
  • CDI specialist’s role in linking the clinical language to the coding language
  • physician and hospital profiling  
  • Case Mix Index including a comparison of CMI with hospitals in the area
  • Severity of Illness/Risk of Mortality with comparisons of adjusted ROM with hospitals in the area and with the state average
  • potential causes of high risk adjusted mortality focusing on the need for complete and specific physician documentation
Peterson’s feedback to Borrego and Limo was that the physicians “have a very positive attitude towards need for SVMH to aspire for better profiling reports and that better physician documentation was a major key to obtaining such results,” Borrego says.
But the CDI team didn’t leave physician education there. They came up with a congratulatory certificate for physicians when they provide specific and accurate documentation without being queried.
“The certificate is printed in color and placed in the medical chart for all clinicians to see while the patient is still in-house,” Limo says. “The physicians have enjoyed the certificate and our facility has even used them to award and recognize physicians for their great efforts.”
Borrego and Limo shared their certificate with ACDIS members. It can be downloaded from the Forms & Tools Library on the ACDIS Web site.

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