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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.

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