Note from the instructor: Increase understanding of pathophysiological concepts for CDI

by Laurie L. Prescott, MSN, RN, CCDS, CDIP

CDI specialists depend on clinical indicators to support queries. Hospitals and physicians need clinical indicators to support the validity of documented diagnoses.

Clinical indicators include patient presentation, symptoms and complaints, lab and diagnostic studies, and ordered treatments such as medications, interventions, monitoring, and assessments. You can find clinical indicators in the documentation of nursing and ancillary staff. As part of our work with clinical validation, all CDI specialists and coders have to work with providers to ensure diagnoses are well supported within the record. It is not enough to obtain documentation of a diagnosis; we must ensure the record clearly supports its presence.

To concentrate on these issues, we have developed a new boot camp to help increase understanding of pathophysiological concepts. The Mastering Clinical Concepts in CDI Boot Camp is designed to assist in the process of clinical validity reviews by examining a number of diagnoses common to both CDI and audit challenges. The Boot Camp discusses diagnostic interpretations, signs and symptoms, and common treatments and covers interventions to strengthen students’ knowledge and competence in record review.

These concepts will assist CDI teams in identifying vague or missing diagnoses regarding neuro, respiratory, cardiac, gastric, liver, musculoskeletal, endocrine, and renal diseases among others and increase staff confidence in speaking to providers and working to ensure adequate documentation in the record. During class, we use real-life scenarios to drive discussions about challenging CDI reviews and help our students:

• Increase your understanding of key pathophysiological concepts 
• Improve the quality of clinical indicators used when you query 
• Cultivate critical thinking skills for use with data involving complex clinical concepts 
• Improve your ability to distinguish evidence-based clinical indicators from other data in the record 

I’m looking forward to teaching this new boot camp aimed at experienced CDI professionals looking to advance their careers with next step training. This course is also valuable for coding staff who wish to increase their clinical understanding of the records they review.

We look forward to seeing you in class!

Editor’s note: Prescott is the CDI education director for ACDIS/HCPro. She is a frequent speaker and author of The Clinical Documentation Improvement Specialist’s Complete Training Guide.