Tip: Teach scribes about CDI in physician clinics
“One of the key components for a successful CDI program is the ability to review records concurrently […] Since the documentation takes place so rapidly in the outpatient world, though, concurrent review is difficult,” said Tammy Combs, RN, MSN, CDIP, CCS, CCDS, director and lead nurse planner of HIM Practice Excellence for AHIMA, on the July 18 episode of Talk10Tuesday.
As CDI expands to the outpatient setting, the rapidity of the concurrent documentation proves an ongoing challenge, says Combs. Medical scribes, however, can be the perfect people to advance CDI efforts in this setting.
“The professionals who have traditionally taken these roles have not had CDI training,” she said. “The relationship, though, could support the concurrent review and query process that’s been so successful in the inpatient area.”
By training the scribes in proper documentation, the CDI team can extend its reach into the concurrent space even in the busy outpatient physician practice setting.
Plus, Combs said, training the scribes can help future CDI programs with physician engagement. Scribe positions are often filled by medical students—40% of whom, according to a recent survey, have never even heard of CDI. This may be a way to get to these students while they’re young and before they’re responsible for their own documentation.
Physician practices can be busy places with physicians often seeing 20 patients per day, according to Combs. Training the scribes in CDI helps to free up the physicians’ time later when they would be addressing retrospective queries.
After all, Combs said, “If it was us or one of our family members, do we want the physician thinking more about our problems or the documentation requirements?”
Editor’s note: To listen to the July 18 episode of Talk10Tuesday, click here. To read a recent article in the CDI Journal about medical students’ awareness of CDI, click here. To listen to a recent free webinar about hospital resident CDI education, click here.