In part 1 of the CDI series, we discussed how allocating resources to CDI training and development is an investment that will produce future returns for health care organisations.
Successful CDI programs appoint a CDI Specialist (CDIS) to ensure the documentation fully reflects the patient’s episode of care. This process enhances patient outcomes1 and, in turn, enables complete and accurate coding and the allocation of an appropriate case-mix group (CMG) assignment.
What is the role of a CDIS?
A qualified CDIS is the cornerstone of an effective CDI program.
Their key role is to perform chart reviews from a clinical perspective, keeping in mind disease processes, symptomology, and appropriate treatment. Physician documentation is often noted in clinical terminology, not always listing the diagnostic equivalent. Often a condition or sign and symptom is recorded. But, the question remains: what is the significance? What is the actual diagnosis, and was it treated?
The CDIS ensures the documentation fully reflects the patient’s episode of care.
Other roles of a CDIS include:
- Acting as a liaison between the coding team and clinicians
- Analysing data and performance metrics to focus CDI efforts
- Developing tools and resources to support both coding staff and clinicians
- Providing training materials and delivering education
- Implementing solutions to leverage available technologies and electronic health record systems
What are the qualifications for a CDIS?
A CDIS may be a Health Information Management (HIM) professional, nurse, or other regulated health professional with a strong foundation in anatomy, physiology, pathophysiology, and pharmacology. As the goal of CDI is to improve the accuracy and completeness of clinical documentation, these individuals are best trained to assess the clinical evidence and follow through with querying and education.
To derive the required results efficiently, the CDI Specialist must have a wide scope of clinical knowledge and critical thinking skills, as well as a good understanding of the provincial funding system, clinical documentation principles, quality metrics, and coding standards.
In addition to the clinical perspective, the coding perspective is necessary to ensure that the gaps in documentation identified are of importance, such as those that have the most potential for impact on length of stay (LOS), complexity level, quality metrics, and funding.
Hear from a CDIS in their own words.
Nicole Taylor-White, a CDI Specialist at Bluewater Health in Sarnia, Ontario, completed the 3M Clinical Documentation Improvement Specialist Program. She describes her role in the organisation, the challenges she has faced, and the importance of a strong relationship with both the clinical and coding teams. Listen here.
Learn more about the skills required to be an effective CDIS.
Our team of CDI experts at 3M have tailored a course for you to maximize your impact as a CDIS in your organisation. To learn more, visit our page here.