Certain parts of important industries and institutions are not just for the people working there to know and understand. With places of public interest that help people, like hospitals and other medical facilities for example, there is a great deal of information that needs to be widespread and available. Making sure the patients know about them is crucial and yet common folk know little about some of them. One of the aspects that definitely needs to have more light shed on it is clinical documentation.
Keeping records of patients and establishing optimal databases is a must in the modern society dominated by technology. This is why the clinical documentation improvement is so important these days. The movement aims to better our relationship with important medical documentation so that everyone benefits. In this article we will discuss it in greater detail and reveal to you the most important things worth knowing about clinical documentation improvement. You can find out more about this from the experts at Pinson & Tang.
1. What Is It?
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Although it may sound complicated at first, clinical documentation improvement (CDI) is not a very foreign concept at all. It is actually the process of enhancing and improving healthcare records in order to establish accurate reimbursements, medical history, patient outcomes, and high-quality data tracking.
When introduced appropriately, it ensures that all of the patient information is accurate, available, organized, and readable for when it is needed. Every patient has their own set of records and diagnoses which are then used when or if there is a new health issue. When done completely and successfully, each patient has an accurate clinical status and a clear set of documents.
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2. Why It Matters?
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This approach is important for more than a few reasons. First of all, it translates to coded data used for public health. When something is being tracked and documented diligently and within a timely manner, everyone involved benefits.
Physician report cards and disease tracking are crucial in treating patients no matter how serious their problems are, and they are possible when clinical documentation is not lacking.
Medical research benefits from this data too. By simply having more information to use in research, the whole science behind is far better off and humanity is able to make progress better and faster. Quality reporting cannot and does not hurt and it is always something to worth striving for.
3. Clinical Documentation Improvement Plans
In order to make such an improvement, there needs to be a concrete plan of action that the medical staff can base their approach on. A plan like this is a comprehensive, multidisciplinary hospital-wide effort with the right terminology and descriptions of every patient and their condition.
It is a change that needs to happen at every level of the medical facility and the entire workforce has to be on board with it. Translation of this terminology is then made using correct codes after which CDI experts can confirm the accuracy of medical record documentation.
The program is deemed successful only when it displays the correct diagnosis for every patient and when they receive the right treatment based on the new documentation. The quality of care skyrockets whenever the implementation is done correctly.
4. Who Uses CDI?
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Now that you know a bit more about what it is and how it works, let us see who uses clinical documentation improvement. This is meant for the clinicians, the clinical documentation specialists, and for inpatient coders. Each of them has a special role in the whole CDI plan and they are all important in its proper introduction.
The clinicians include licensed healthcare professionals like doctors of medicine, nurse practitioners and anesthetists, doctors of osteopathic medicine, podiatric medicine, various assistants, and more. Laboratory and care management employees are also involved. All of them need to be familiar with the patients and their medical documentation in order to properly give them care. The documentation they make and use affects every step that comes after.
CDI specialists are the ones who review the medical records and collect any and all useful clinical information. While the patients are at the hospital, they are actively collecting anything that can be considered clinical documentation and adding it to the records.
Their tasks include asking clinicians for clarifications and explanations as well as additional documentation to use the correct codes within patient records. A large part of their job revolves around giving educational presentations to the medical staff during conferences and meetings. The specialists then exchange their information with inpatient coders.
Speaking of coders, these experts are the ones who translate the clinician’s documentation into special codes. This means that the CDI specialists are mediators between the clinicians and the coders. The whole process requires all three sides to come together and cooperate optimally in order to be successful and to make sense.
Inpatient coders make sure the medical codes reflect the condition(s) of the patients. They are trained in understanding, reading, and changing diagnostic criteria and clinical terminology that arises in CDI processes. Coders are always on the lookout to improve coding guidelines, code selection, and sequencing. They report directly to the chief officer of the hospital, a testament to their importance in the collective.
5. Key Elements
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For the CDI process to be implemented correctly, the plan needs to have three key elements. They include the physicians’ input, CDI leaders, and quality information. The CDI team picks a physician to be the leader and they have to have good leadership skills, be a good communicator, and be passionate about clinical documentation. They receive necessary education and training and become the hospital’s lead CDI expert among physicians.
The CDI leaders are certified and have experience in nursing, pharmacy, or health information management. They know a lot about federal and state requirements for the coding, reporting, and documentation which are all useful in CDI planning. Every CDI leader is aware of the all the elements that make up high-quality clinical documentation so that their team can use it properly.
Lastly, quality information means that clinical documentation is reliable, clear, legible, consistent, complete, timely, and precise. None of these factors can be missing from the collective clinical history of a hospital. It is the final mission of the whole medical facility to achieve quality information as a result of their new CDI plan.