Q&A: Expanding CDI efforts in the quality arena

Q: When did the CDI program at Wake Forest University Baptist Medical Center start getting involved in looking at quality-related documentation concerns and what was the impetus for the evolution?

A: It started with pressure ulcers. Back in 2011/2012 the nursing leadership requested our assistance to identify present on admission status of any pressure ulcers. This quickly expanded to include other HACs and now PSIs.

Initially, we found that pressure ulcers were being documenting at the time of arrival by our nursing staff, but the physicians were not including this documentation in their assessment. After working with several physicians, we identified a major barrier within our EMR. The physicians did not know how or were unable to view the nursing flow sheets.

So we completed aggressive education across our medical center to promote knowledge, understanding, and importance of correct documentation. Things have improved tremendously with our pressure ulcer documentation today, and with modern technology we have the ability to capture/ identify potential areas of concern electronically.

Our efforts with our quality initiatives are solid and growing daily. We have a dedicated clinical documentation compliance coordinator who has our process in place. We have multiple individuals within our team with advanced knowledge of HACs, PSIs, Meaningful Use (MU), and Value Based Purchasing (VBP). It is our goal to consistently have a resource available to provide education for both staff and physicians/providers if needed.

By identifying these issues when the documentation first appears in the chart, we can implement measures to address, correct, or even remove the documentation if needed. Once something is copied and pasted forward in the record over several days, it is very difficult to have the documentation corrected or removed by the care team.

Editor's Note: Melinda Matthews, RN, BSN, CCDS, supervisor of inpatient CDI at Wake Forest University Baptist Medical Center including Brenner Children’s Hospital Winston-Salem, North Carolina, answered this question as part of the fifth annual Clinical Documentation Improvement Week.