CDI: Clinical Documentation Improvement

Team Summary

There are 18 CDI Nurses and we are directed by our fearless leaders Deanna Brennan, Melissa Vermillion and Deborah Cook. We cover all inpatient units, except NICU, Inpatient Psych, Oral Surgery and Urology.  

Team Fact: In our department, we have a total of 324 years of collective healthcare experience, we have five masters prepared nurses, and seven nurses with active certifications.

The Department’s Primary Function

Have you heard, “If it isn’t documented, it didn’t happen”?  Our job is to review inpatient documentation every day to ensure that it is an accurate reflection of severity of illness and intensity of service that results in appropriate MS-DRG assignment.  We impact patient care by collaborating with LIPs, dietitians, and nursing to ensure that the complete patient story is documented and that we achieve total patient care through the eyes of the record. Accurate documentation and hospital coding has a positive impact on our length of stay, quality and safety metrics, and hospital reimbursement.

Current Goals and Focus

  • Our Working DRG matching the final hospital coder DRG at least 75% of the time.
  • Increasing the Case Mix Index, Severity of Illness, and Risk of Mortality calculations for our inpatients.
  • Ensuring accuracy of our publicly reported safety metrics (i.e. HAC, AHRQ Safety Indicators).

In the last few years, we have collaborated with other departments to:

  • Create Clinical Guidelines within the Clinical Documentation Handbook.
  • Develop Dot Phrases that can be used by our physicians to respond to documentation queries.
  • Achieve house wide implementation of the interventions from the adult and pediatric malnutrition Pilots.
  • Provide ongoing provider education and unit Specific Top 10 Lists of documentation opportunities.

CDI Biographies

*alphabetical by last name