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February 5, 2020

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The Future Can Be Bright...


 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 available to the physicians for purposes of discussing cases with pertinent opportunities for documentation enhancement. Ultimately, the goal of his CDI program is to expand efforts at improving the depth and breadth of the documentation to the extent the record best communicates and portrays the quality of care and outcomes achieved. An additional goal of the CDI program is to reduce the number of queries for diagnoses, getting the documentation right the first time without the need for repetitive transactional queries for the same diagnoses every day. This affords more time and energy to collaborate with physicians in a more proactive participatory manner to improve the quality, completeness and accuracy in documentation of the patient's story.