Margie White Wellness Center

1. Margie White Wellness Center Clinical Documentation Improvement Program (CDI)

2. Coded data quality is the cornerstone of data integrity and the foundation for all service billing Implement a Clinical Documentation Improvement Program (CDI) that meets our internal core needs and addresses specific risks

3. Clinical documentation is the basis for all coding done in every healthcare facility. An effective CDI program can have a positive impact on the accuracy of the reimbursement, quality ratings, planning data, and the acquisition of data for research purposes. It can also improve clinical documentation and provide mechanism for the coding staff to communicate with physicians.

4. The 7 Qualities for High-Quality Clinical Documentation: Legible - Clear enough to be read and easily deciphered. Reliable – Trustworthy & safe; yielding the same result when repeated. Precise– Accurate, exact, & strictly defined; evidenced by the level of detail in the documentation. Complete - Having the maximum content (thorough). All concerns in the record are addressed.

5. The 7 Qualities for High-Quality Clinical Documentation: • Consistent - Not contradictory. From start to finish, documentation makes sense in relation to the rest of the documentation in the record. • Clear – Unambiguous, intelligible, and not vague; states the cause of the patient’s symptoms. • Timely - At the right time.

6. Goals of a Clinical Documentation Improvement Program

7. Goals of a Clinical Documentation Improvement Program Establish ongoing monitor for identifying problems or opportunities to improve quality of coded data Identify variations in coding practices among staff members Determine cause and scope of identified problems Set priorities for resolving identified problems

8. Goals of a Clinical Documentation Improvement Program Implement mechanisms for problem solving through approval of corrective action plans Ensure that corrective action is taken by following up on problems with appropriate monitors Ensure compliance while meeting organizational needs

9. Key Types and Sources of Documentation Attending Physician Documentation Includes patient’s history and physical examination, problem list (plan of care for each problem), orders for treatment and services, documented condition, diagnostic test results, and response to treatment.

10. Key Types and Sources of Documentation • Consultants - Consultant report based on patient examination and review of the medical record. • House Staff – Interns, residents, and fellows may document the history and physical examination, operative reports, discharge summary, and progress notes. Other physician documentation

11. Key Types and Sources of Documentation • Diagnostic test results – such as laboratory results, pathology reports, and radiology reports. • Midlevel practitioners – including nurse practitioners, and physician assistants. Other Clinical Documentation – diagnosticians, midlevel practitioners, nurses, other specialty professionals, and medical students.

12. Key Types and Sources of Documentation Nurses, Nutritionists, &Therapists Documentation includes physical findings, educational efforts, treatments provided, and patient’s response to those treatments

13. Steps to Development and Implementation of a CDI Program Executive support - Including CEO, CFO Medical staff support

14. Steps to Development and Implementation of a CDI Program Oversight Committee - Determine the mission and scope of the program. Develop a strategic communication plan and oversee operations of the program. • Medical staff • Operations • Finance • HIM • Case management • Nursing • Compliance • Quality

15. Steps to Development and Implementation of a CDI Program • Program staff: Clinical documentation specialists- Review records and interact with physicians Conduct follow-up education with physicians • Physician staff: Program advisor Support for CDS staff

16. Works Cited Schraffenberger, L. A., & Kuehn, L. (2011). Effective Management of Coding Services. Chicago: AHIMA.