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Specialists Play Key Role in Clinical Documentation Program at Crozer

From left to right are clinical documentation specialists Lisa Orr, R.N., Fran Tillman, RHIA, and Noreen Peck, R.N.

In July, Crozer-Chester Medical Center embarked on an initiative called the Clinical Documentation Improvement program (CDI) in collaboration with Navigant Consulting Company.

The goal of the program is to focus on clinical documentation at the point of service, while the patient is still in the hospital. Due to an increasing number of public scorecards and reimbursement challenges, hospitals can benefit from a CDI program by ensuring accurate reporting of the acuity of each patient treated. Severity of illness and risk of mortality are some points that affect the quality outcomes of a medical institution that many insurance companies take into consideration when calculating payments to their customers. Specific and correct clinical documentation is the primary driver for a hospital’s inpatient reimbursement.

To meet the goals of this initiative, Crozer hired three specialists to concurrently review clinical documentation at the nursing units and identify any documentation opportunities. The specialists — Lisa Orr, R.N.; Fran Tillman, RHIA; and Noreen Peck, R.N., review patient charts, and speak to and educate physicians regarding documentation specificity.

When clinical language in the chart is nebulous, the specialists query the physician by placing a ‘Query Form’ in the progress notes of the chart. The query forms are diagnosis and condition specific and request that the clinician answer the question within the body of the medical record. Along with the documentation specialists, Crozer hired a physician advocate, Ned Russell, M.D., a retired surgeon, to assist with physician documentation best practices and to provide support of the program from a physician standpoint.

A software tool is used to monitor questions asked, individual physician response rate, financial impact and other important measurable criteria. Each month, a steering committee reviews the information generated from the software tool to assess the effectiveness of the initiative.

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