Clinical Doc. Improvement Scenario: You have been asked to lead a Clinical Docum

Question

Clinical Doc. Improvement

Scenario: You have been asked to lead a Clinical Documentation Improvement (CDI) initiative. This small rural hospital is a 30-bed, fully paper-health dependent facility. Although the purchase and implementation of an EHR is not feasible at this time due to the accompanying price tag and other impacting factors, the hospital administrator recognizes although the EHR is currently out of reach, the importance of developing a CDI program is ultimately, a step in the right direction. Revisit your Week 3 “Health Record Documentation Policy” (paper-based record policy only) and Week 4 “Data Quality Beyond Borders: Modernizing Health Information Infrastructure Using AHIMA’s Data Quality Model” assignments that has been critiqued by your Professor. Using both materials from weeks three and four, devise a five (5) to seven (7) page briefing to the Chief of Staff also known as the Chief Medical Officer which outlines the following listed below.

Deliverables:

Overview/description of the Clinical Documentation Improvement (CDI)

The benefits of implementing a CDI program

Consequences of not implementing such a program

List and briefly discuss at least six elements of a sound health record; from the perspective of a CDI program emphasis on quality documentation practices

The significant role of physicians as it relates to timely, accurate, complete and legible health record documentation practices and the timely response to physician queries within 48-72 hours upon receipt. Outline the process of the department’s physician query process

How the HIM department will lead the initiative. How the HIM staff can/will assist the Chief of Staff and the entire pool of practicing physicians

Finally, devise a 1-page six (6) month timeline which outlines the planning, designing and implementation of your proposed CDI program (not counted towards the five (5) to seven (7) page requirement; list as an appendix)

Explanation / Answer

The need of hour is to develop such a system which helps in providing the correct data of a patient in an easy way and CDI does that as it facilitate the accurate representation of a patient's medical status that translates into coded data. Coded data is then translated into quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending.

BENEFITS- Mostly patients visit any hospital again and again and if the history is unknown then lot of time, money etc will be involved in repeated tests. CDI has a direct impact on patient care by providing information to all members of the care team, as well as those downstream who may be treating the patient at a later date. Even the convergence of clinical, documentation, and coding processes is vital to a healthy revenue cycle, and more important, to a healthy patient. So a well qualified CDI specialist is must who can manage clinical trial and service documents in order to ensure accuracy and quality among medical coders, doctors and other healthcare staff. Main job of a CDI is to maintain charts, medical records, and reports and solve any issues involving documentation. The oding of any disease may apparently become more accurate and sicker patients who actually had sepsis or respiratory failure are documented and coded as such in case of pneumonia. Further, CDI solutions can be the helpful in ensuring full and timelier reimbursements from insurers and payers, as well as avoiding costly penalties for non-compliance.

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