“Even if you don’t have a title, you can be a leader if you’re passionate and have a desire to change a process that’s not working,” said Judy Schade, RN, MSN, CCM, CCDS, CDI specialist at the Mayo Clinic Hospital, on the May 18 Quarterly Conference Call. She spoke in regard to...Read More »
Despite CDI programs’ 10-plus years of existence, physician engagement continually ranks as the number one concern for CDI departments, according to the 2017 ACDIS Membership Survey. Part of this challenge may stem from the fact that, although some methods work better than others, physicians are...Read More »
Q: I encountered clinical validation issues where documentation noted a diagnosis with criteria, but the criteria used didn't meet the definition. For example, noted sepsis with criteria of tachycardia and increased white blood cell (WBC) count. But, the patient’s heart rate (HR...Read More »
A number of inpatient prospective payment system changes in recent years, due primarily to the Affordable Care Act, have allowed CMS to adjust healthcare reimbursement based on quality metrics and data. But some providers are unaware that many quality scores for themselves and hospitals are...Read More »
In its 2013 position paper, “Electronic Health Records and the Role of the CDI Specialist,” members of the ACDIS Advisory Board addressed several concerns related to challenges and opportunities emerging with the advent of electronic systems. Among them were how to handle copy-and-paste concerns...Read More »
Okemena Ewoterai used to take a folder off a shelf and peer through the papers inside looking for hints—scraps of stories that could lead her to a better understanding of why a particular patient needed to be in her hospital. When she found them, Ewoterai would pull out a piece...Read More »
Queries are definitely not what they used to be. When I first started as a CDI specialist, back when dinosaurs roamed the earth, the query process was a muddy exercise in creative writing.Read More »
By Marion Kruse, BSN, RN, MBA, and Jennifer Cavagnac, CCDS
Every CDI program should objectively evaluate the outcomes, processes, and compliance of their CDI efforts. Auditing and monitoring provides oversight for the CDI program, insight into physician documentation and...Read More »
