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Clinical Documentation Improvement: The Quest Enabled by Nursing

I’ve had diverse, interesting, and fulfilling experiences in my nursing career, but when I started out, I did not ever think that today I would be working with clinical terminology to improve clinical documentation. I started on a medical/surgical unit, then two years later moved to an inpatient rehab unit working with stroke and spinal cord injury patients. Nursing offers so many opportunities and I wanted to continue my education. I obtained my MBA and was licensed as a nursing home administrator and went on to be the administrator for two different hospital based skilled nursing units. MedChartWriting400

After experiencing both direct patient care and nursing administration, I was still interested in exploring other opportunities related to nursing. I began working for an insurance company
managing the nurses that did medical bill auditing for their worker’s compensation and auto claims. The job required a review of the clinical documentation in comparison to the medical bill coding that was submitted. To better evaluate the documentation requirements, I obtained my CPC (Certified Professional Coder) credentials. During the clinical reviews, it was amazing to see how the coding on the medical bills truly lacked support from the clinical documentation. That sparked my interest in opportunities that existed in the realm of clinical documentation improvement (CDI).

Joining 3M/MModal offered the opportunity to support CDI nurses with a tool that presents the evidence they need to query the physicians when specificity is lacking in patient documentation.
The tool also presents information to the CDI nurse on medical conditions where the documentation already meets the clinical standards for coding. Finally, my combined clinical background and familiarity with medical coding provides the opportunity for me to help bridge the gap between the frontline clinician and the engineering team to create a product that makes the CDI specialist’s job much easier.

Using clinical knowledge, my colleagues and I create content for a product that pulls information
from various clinical documents within the patient chart. The evidence from physician documentation, laboratory reports, diagnostic imaging, interventional radiology, procedure reports and ancillary documentation are presented to the CDI specialist in real time as the information is produced. The CDI specialist then can determine if the information warrants a query to the physician for more specificity to clarify the condition being treated. We use our clinical background to work together with the engineers to improve the CDI product’s ability to interpret the meaning of the documentation and correctly present the available evidence to the CDI specialist to ensure that the billing information is supported by the documentation and that the patient’s record accurately reflects the care that they receive.

My nursing journey has landed me where I am making use of all that I’ve explored and learned to help clinicians and patients – a great destination to be!

 

 

 

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  • Last modified on Thursday, 16 June 2022 12:04