Case study: How Clinical Documentation Essentials for the Hospital Resident helped one teaching hospital

“Physicians have never been taught documenting for coding based reasons; they’ve always been taught documenting for clinical reasons,” says Timothy N. Brundage, MD, CCDS, medical director of Brundage Medical Group, LLC, in Redington Beach, Florida, and one of the co-authors of the Clinical Documentation Essentials for the Hospital Resident e-learning course.

While every CDI program has a query process in place, that alone will not directly change your physician engagement and knowledge numbers. “If you were to give a query to a physician, they may answer that query in the way that you wanted, but the physician will make the same mistake over and over again,” Brundage says.

In order to truly educate residents as to the benefit of accurate documentation and coding, they need more than just a query. They need in-depth education and training.

Enter Clinical Documentation Essentials for the Hospital Resident.

“This course gives them a little bit of DRG background, a little understanding of documentation and coding, quality, and how quality is tracked, how physician metrics are tracked, and a little understanding of clinical criteria to make diagnoses and what words to use when making that diagnosis,” Brundage says about the outline of his course. “Each section is a short educational section. Some focus on coding, some on policies, some on coding guidelines, some on clinical criteria separated by body system.”

For more information, read the attached case study.