Clinical Documentation Improvement CDI Update

Posted on Apr 7, 2017 in Clinical Documentation | 0 comments

In the past year there has been noticeable improvement in physician clinical documentation.

By this I mean that our documentation is more precise as more of us indicate Acuity, Co-Morbidities, Linkage and Specificity for each diagnosis. (I call this mnemonic “the other ACLS”).

For example: in the case of your patient with COPD who uses oxygen at home and is a CO2 retainer who is admitted because of increasing dyspnea, worse ABG, unchanged CxR, you would document “acute on chronic hypoxemic and hypercarbic respiratory failure due to an acute exacerbation of COPD”.

In order to build on this improvement trend, Sutter has contracted with Nuance Corporation to assist physicians with ongoing clinical documentation optimization. The service is in the form of CDI queries—these are similar to the existing Sutter CDI queries, with a somewhat simplified format. For now, you might see both types of CDI queries. You will find these queries in the “progress note” section in EPIC. The important thing is to answer the queries promptly, so remember to check your inbox for unanswered queries before you go off service. (CDI queries are usually generated while the patient is still in the hospital, whereas coding queries are sent by coding personnel and are created after discharge).

 I cannot overstate how much physician documentation matters—it’s the way we convey how ill our patients are and verifies our treatments and our patients’ clinical progress. Our documentation also affects assignment of proper DRGs, severity of illness and risk of mortality scores and observed:expected calculations and other quality metrics.

 CDI queries can serve as educational reminders to make sure our documentation is as accurate and complete as possible.

 From Merry Beth Gong, MD, CDI Physician Champion