In my continued quest to provide feedback to physicians on best strategies for enhanced communication of patient care focusing upon medical necessity denials, I notice a common theme, ineffective communication within the record, particularly when consultants are on board. There appears to be little collaboration between physicians on the case attributable to insufficient communication. The attending is not driving the ship, tying all the clinical

A fully engaged Clinical Documentation Integrity Specialists possesses an open mind, is inquisitive, has an insatiable appetite for continual learning in all aspects of physician documentation, commits to maintaining relevancy in clinical medicine and standards of documentation, and subscribes to the philosophy of continuous quality improvement. A highly proficient Clinical Documentation Integrity Specialists is not content with the status quo and is always

Palmetto GBA just this week posted on its website an article titled Hospital Readmission Without Septicema discussing the CMS Hospital Readmission Reduction Program. pointing out the cost of unplanned readmissions is $15 to $20 billion annually. Interesting enough the following statements in the article run contrary to findings of a study published in January’s Health Affairs

A recent conversation with a CDI colleague of mine raised several interesting points I would like to share for consideration. We were discussing an initiative where the CDI specialists and their department were going to transition to working on the floor reviewing records with the intent of conversing more with the physicians and residents on documentation improvement opportunities. The impetus of the initiative to transition to the floor was to be more readily

Any clinical documentation integrity initiative must embrace the concept of proactivity versus reactivity, rejecting the reactive tendency of complacency and content. Proactivity facilitates and supports achievement of measurable meaningful improvement in physician documentation that best serve’s the patient’s and all relevant healthcare stakeholder’s needs for accurate and complete communication of patient care. Referring to proactivity, I subscribe to

Complacency is the main contributing factor that leads to suboptimal performance and achievement of sustainable operational processes and outcomes for any business. Clinical documentation improvement programs have discounted the necessity to evolve with the times, overlooking critical opportunities to contribute to the overall welfare of the healthcare delivery model. A strong CDI program for the right reasons with an underlying commitment to achieving

Clinical documentation improvement spans the entire continuum of care from the time the patient presents to the Emergency Department or is direct admitted to the hospital until the time of patient discharge and the completion of the discharge summary. The CDI specialist’s role in enhancing the quality, completeness and effectiveness of clinical documentation is to recognize and treat the record as a communication tool as opposed to a reimbursement tool.

The majority of CDI programs rely on the query process as the fundamental hallmark of documentation improvement. This query process has steadfastly maintained its stature in the industry as the bell weather for CDI for over twelve years. Recent conversation with several CDI professionals has increased my confidence that early adopters to change in present CDI query processes are finally seeing the light, recognizing the need for CDI redesign and reposition

A major challenge of current clinical documentation improvement processes is the undivided focus upon reimbursement as the primary outcome, something undisputable with a clear review of present day Key Performance Indicators. The expression and reporting of the clinical truth in the record beginning with the Emergency Room Documentation, transitioning into the H & P and continuing with the consultant reports and progress notes culminating in the discharge summary

Clinical Documentation Integrity, previously referred to as Clinical Documentation Improvement, has been a strong passion of mine for the past twenty-seven years, predating the recognition of CDI as a profession. I am always advocating for and will continue to advocate for a radical transformational change in current CDI processes that do not lend themselves to true physician engagement as willing active participants. Active physician engagement beyond