Accurate clinical documentation is essential to patient care. The medical record allows us to have asynchronous communication among the many team members and with our referring physicians. Telling the patient’s story, accurately, in the medical record allows for the highest quality and safest care for our patients. Documentation also lends to appropriate risk assessment of our patients. This is a critical way to assess our quality of care. Finally, clinical documentation leads to medical coding which results in overall payment for inpatient admissions. For all of these reasons, it is our duty as health care professionals to make sure that our documentation is accurate and complete. I have asked Deanna Brennan, director of Clinical Documentation Improvement to lead this month’s blog and discuss accurate and complete documentation.
As we move into the month of May, I am excited to have the opportunity to share our program with you and answer your questions regarding how clinical documentation impacts our organization and why it’s such an important piece of your daily work. As the director of our Clinical Documentation Improvement department for the past three years, I have had the opportunity to hear the daily frustrations that many of you have regarding documentation requirements, queries, and coding nuances. One of the most common questions I hear from providers is, “What difference does it make?” To answer that question, your documentation has the potential to make a tremendous difference in accurately reporting the complexity and acuity of the patients you care for. In turn, this data is used to show the excellent care that we give, and that University of Iowa Hospitals & Clinics is a high-quality organization that cares for highly complex patients with excellent patient outcomes.
Clinical Documentation Improvement programs are an integral part of health care facilities across the nation, facilitating high level accuracy of documentation and coding. These programs are made up of clinical documentation specialists that partner with providers and coding teams to impact documentation quality, patient outcomes, and accuracy of data analytics. UI Hospitals & Clinics implemented the Clinical Documentation program in 2004, with the assistance of eight “DRG nurses” who reviewed charts and assigned a documentation related grouper (DRG) that reflected the patients’ care needs, acuity of illness and expected length of stay. As focus on documentation and coding increases, the UI Hospitals & Clinics program has evolved to take on new projects, challenges, and improved engagement strategies to help our organization achieve its mission.
Through its daily efforts, the Clinical Documentation Improvement (CDI) team works with providers to ensure medical records contain a complete and accurate picture of the patient’s level of care, severity of illness, and risk of mortality, while also supporting necessary resource utilization. The CDI nurses help to ensure that the record supports accurate capture of documentation codes, statistical data, quality metrics, and reimbursement. This is accomplished through ongoing education and collaboration among the CDI nurses and various specialty teams.
The department works as a liaison service for multiple areas of the hospital, using data analytics to identify areas of opportunity for improved documentation. CDI uses a teamwork mentality to partner with services, provide education, and identify areas of focus to improve documentation accuracy. The department provides regular feedback to providers regarding individual patient records, takes part in chart review discussions, and provides resources for documentation improvement.
Our department is comprised of 16 clinical documentation specialty nurses and a quality oversight specialist. The team’s primary purpose is concurrent review of medical records to improve accuracy, clarity, and specificity of provider documentation. They bridge the gap between providers and hospital coders by clarifying at-risk documentation prior to claim submission. They collaborate extensively with physicians, coding staff, and other patient caregivers to improve accuracy and completeness of acute inpatient documentation. They must adhere to ethical and professional business practices as governed by the Association of Clinical Documentation Improvement Specialists (ACDIS) and the American Health Information Management Association (AHIMA).
Clinical Documentation Improvement is a specialized field that utilizes highly experienced nurses with a diverse clinical background, requiring them to acquire proficient coding skills and knowledge. CDI nurses must have the ability and willingness to seek out changes in healthcare reform and coding regulations, then incorporate those changes into their practice. These nurses must possess a high level of organization and computer skills, comprehensive medical knowledge, and utilize effective communication. These capabilities help them to identify gaps in the clinical documentation.
The CDI department at UI Hospitals & Clinics is an excellent resource for providers wishing to increase their knowledge of documentation requirements and improve accuracy and completeness of medical records. In the past year, CDI has partnered with a variety of specialty services, such as the Heart and Vascular Center and neurosurgery, to help identify opportunities for documentation improvement for accuracy and completeness. CDI continues to look for opportunities to educate, collaborate, and improve clinical documentation throughout our organization. If you or your team wish for increased engagement from the CDI program or if you wish to learn more about documentation improvement and engage in educational opportunities, please contact our program with information below.
Thank you for the excellent care you give to our patients and for your attention to the impact that your medical record documentation has on our organization.
Deanna Brennan, RN, BSN, CCDS
Clinical Documentation Improvement manager/director
Clinical Documentation Improvement
Pager #5496 or CDI-RN@uiowa.edu
Manager/director: Deanna Brennan, firstname.lastname@example.org
Quality oversight specialist: Jaime Sherman, Jaimeemail@example.com