How Can CDI Truly Make A Difference?
Glenn Krauss
Creator and Founder of Core- CDI; Co-Founder of Top Gun Audit School------ Physician Advocate & Champion-Partnering with Physicians to Help Achieve Physician Documentation Excellence----While Working Smarter-Not Harder
A common statement I hear regarding CDI is that our efforts at securing additional documentation positively impact quality of care reporting. Quality care can be certainly defined in a host of diverse ways but for sake of argument and simplicity I refer to quality in healthcare as the right care at the right time for the right reason with the right documentation in the right setting with the right clinical judgment and clear demonstration of appropriate use criteria. Fundamental to this definition is concise, complete and consistent documentation including accurate reporting of all clinically relevant diagnoses pertinent to an encounter.
How does CDI truly make a difference in validity and reliability of quality reporting? By truly focusing upon actual documentation improvement. A recent post on LinkedIn related to CDI that alluded to the notion physicians don't have time to document their clinical judgment and medical decision making because of all their competing forces in patient care is misdirected, characterizing what ails our profession. Inarguably, good patient care strongly correlates with superior quality documentation. Simply put, clinical judgment and medical decision making form the basis for the practice of medicine, requiring solid documentation that is inarguably not optional.
As a profession, it is incumbent upon us to be capable of sharing documentation insufficiencies prevalent in reviewed charts. Take for example spinal fusions and CMS focus upon medical necessity. Here are some resources from CMS to increase our awareness of documentation insufficiencies contributing to questions of medical necessity and quality of medicine. We should be at the forefront of sharing this information with our constituents, our physicians, especially since the name of our profession is “clinical documentation improvement.”
https://www.youtube.com/watch?v=rr8C15-ybB4&index=5&list=PLaV7m2-zFKpigb1UvmCh1Q2cBKi1SGk-V