Celebrating National Clinical Documentation Improvement Week (Sept. 18-24)

WellStar Cobb Hospital Clinical Documentation Specialists with hospitalist, Dr. Hindi.

WellStar Kennestone Hospital Clinical Documentation Specialists with (2nd from left) Dr. Ricky Washington, hospitalist; (3rd from left) Sheri Chazen, PAC, Urology Associates and (4th from left) Dr. Beau Dusseault, Urology Associates.

WellStar Kennestone, Cobb and Douglas Hospitals’ medical staff celebrated the Association of Clinical Documentation Specialist’s first annual Clinical Documentation Improvement Week with snacks and clinical documentation improvement tips offered by WellStar’s Clinical Documentation Specialists.

Clinical Documentation Specialists are part of the WellStar Health System’s Clinical Documentation Improvement (CDI) Program, which is designed to ensure that clinical documentation in a patient’s medical record appropriately reflects the care provided. The most vital role of the CDI program is facilitating a true representation of healthcare services provided, through accurate reporting of the principal diagnosis, co-morbidities and any treatments or procedures.
Coding rules and regulatory requirements often differ from the way physicians are trained to document their clinical thought processes. Clinical documentation specialists are knowledgeable in interpreting physician documentation and can identify opportunities to bridge the differences between clinical language and coding terms. The CDI professional works to facilitate the overall quality and completeness of clinical documentation to accurately represent the severity, acuity and risk of mortality profile of the patient being treated.

WellStar Health System’s Gold Standards of Clinical Documentation Improvement
As part of the program’s ongoing efforts, the CDI team will be providing monthly general and body system specific tips from the Program’s Gold Standards of Clinical Documentation Improvement in this and future issues of Medical Staff News.

Tips of the Month:
General:

• Clearly document the patient’s “reason/diagnosis for admission”
• If the patient’s reason for admission is a symptom, document the likely cause including probable, possible, suspected or differential diagnoses

Circulatory system:

• CHF: clarify type and acuity: acute, chronic or acute on chronic along with diastolic, systolic or combined
• Cardiomyopathy documented with EF is not synonymous with heart failure in coding terms
• Hypertension: please clarify as accelerated or malignant when present
• Angina clarify cause when known or suspected such as: post MI syndrome, progressing CAD, Prinzmetal, Accelerated or Dressler’s syndrome
• Chest pain indicate likely underlying cause i.e cardiac arrhythmia, pleuritc, GERD, CAD, psychogenic

If you have questions or need more information about the CDI Program, please contact:

Katrina Allen, Supervisor, Clinical Documentation Improvement, WellStar Kennestone and Douglas Hospitals: (770) 842-9731 or Katrina.allen@wellstar.org
or
Darcee Sellari, Supervisor, Clinical Documentation Improvement, WellStar Cobb Hospital: 770-842-1299 or darcee.sellari@wellstar.org