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Correct Documentation is Vital

Making sure a patient’s medical record includes the correct detailed data and treatment information is vital. In addition to ensuring the patient receives the best care possible, capturing the information about that care ensures that the medical record reflects how seriously ill the patient is, the risk of mortality and the level of service needed for proper treatment.

An expanded Clinical Documentation Improvement (CDI) Team in Health Information Management (HIM) is working with physicians to bridge the gap in language between the technical terminology of the coding system and the clinical language physicians use to describe a patient’s condition and treatments. For example, if a physician enters a nonspecific condition such as anemia without classifying the type of anemia, the severity of the patient’s condition may be inaccurate.

Each CDI staff member is assigned to specific nursing units and, in real time while patients are still in the hospital, follow up with physicians to make sure the correct information is captured. The team has a mix of clinical and technical backgrounds, including a nurse, a physician assistant and two certified coders.

Although the functions of the clinical documentation program had been handled by one staff person, Leslie Hack, who was promoted to new CDI manager, the recent Good-2-Great initiative identified the need for more CDI staff. In addition to ensuring that the hospital receives proper payment for services and supplies, the extra, detailed information ensures accurate reporting of services rendered to several different regulatory agencies. Three additional staff members were hired and, along with inpatient coding staff, went through a six-week training program.

Clinical Documentation Improvement Team Members

Marjorie Fuller, RN: ICU, Special Care Unit, Observation Unit, 4 South
Lynda Holley, CCS: 2P, 4P
Rochelle Payne, CCS: 3P and 2 South JAS (Joint Academy/Surgery)
Leslie Hack, PA, Manager: responsible for the retrospective reviews on the Maryland Hospital Acquired Conditions as well as administrative functions, overseeing the team and developing initiatives related to the CDI program