Guest Post: Effective communication equals a CDI nurses’ strength

by Sylvia Hoffman, RN

Good communication is a key attribute of a successful clinical documentation improvement specialist (CDIS). The CDIS must be able to function in a variety of different settings. These include the CDIS office, the patient care unit, and presenting at rounds. All require flexibility, quick thinking, and a sound knowledge of clinical documentation policies.

Many hospitals have been reluctant to use nurses in the role of CDIS, adhering to the belief that nurses cannot be retrained to think like coders. Why would anyone want them to? Nurses bring their own qualities and strengths to the job.

A CDIS nurse must learn to work in an office setting. Computers replace cardiac monitors, printers, copiers, and fax machines replace IV pumps, Dinamaps and Pulse Oximeters. This is not the usual arena in which a registered nurse feels comfortable. Communication is done in varying ways: verbally, by phone, fax, or e-mail. Co-workers talk in coding language and discuss raw weights and DRG’s.

But nurses are no strangers to change and diversity. In this era of modern technical advancement, nurses are frequently challenged to update, renew and reeducate. Nurses chart on computers in many hospitals, they run Ecmo units and program dialysis machines. Nurses wear many hats and adjusting to the business world is no far stretch.

Transitioning from the medical floor presents a bevy of challenges to the CDIS as well. Floor nurses may no longer accept the CDIS as a member of the “clinical” team where they were once embraced.

They must prove themselves to the staff and slowly win acceptance. Physicians are resistant at first; and here too, the CDIS must show perseverance. First, a CDIS should explain their role in documentation improvement in clear, easy to understand terms. Too often clinical staff feel threatened by implications of the query process. If there’s a query he or she must have done something wrong. Be patient. You know physicians and nurses did not go to school to learn how to code. They trained to treat medical conditions. Your role is to help them translate that treatment into the language the administration needs.

Patience is key. A good gift of gab doesn’t hurt, either. CDIS nurses must develop a rapport with the physicians. This where a nurse’s clinical background helps the CDIS program best. Years of talking to patients, families, coworkers, and physicians taught nurses effective communication.

CDIS nurses no longer turn to stethoscopes to see if a patient has unusual breath sounds. Instead, they rely on the physician to properly document atelectasis, or pulmonary congestion. Luckily, the fast pace of hospital work and the intense demand of patient care prepared nurses to be quick on their feet.

CDIS nurses grasp brief moments to help physicians document hyponatremia the most appropriate way. They hand out pocket cards with ease. They know how to get the most from just 10 minutes between physician cases. They run addendums up to the operating room for completion and even hand out candy or other treats to supportive staff members on holidays. The CDI Nurse has an arsenal at their disposal.

The clinical documentation nurse must be a good communicator (salesman, psychiatrist and businessman). Not to worry, for a nurse, it’s all in a days work.

Editor's note: Hoffman, at the time of this article's release, was a CDIS in Tampa Florida. She has been a nurse for more than 20 years and enjoys writing, painting, and travelling.