We have been very excited to see the enthusiasm and support for the Epic Project from across WellStar. We had a tremendous response to our call for internal candidates to be on the Epic Team.
Approximately 675 internal candidates have applied and taken the assessment. We believe we will meet our target of having 80 percent of the positions filled internally. In addition, we have received more than 1,000 external applications.
The offer process for members of the Epic Team will begin on Wednesday, May 16 and we will notify all applicants no later than Friday, June 1. For candidates not selected, there will be future opportunities to be part of the project as part of your current position. We also are finalizing our Epic leadership team and will be announcing those individuals soon.
A home has been secured for our Epic Team at 2700 Cumberland Parkway in the Cobb Galleria area. The entire third floor and part of the second floor will be used to house the Epic team during project implementation. The space includes offices, conference rooms and training facilities. The team will move-in beginning in early June. Thank you for your support of this important project.
Tuesday, May 29, 2012
The Blood Drive Challenge
The recent WellStar Cardiovascular Medicine Blood Drives have sparked a challenge for all physician offices to host blood drives and donate blood at their offices.
At the March and April CVM blood drives, several doctors in the practice were present and donated blood. This shows that CVM physicians have a passion for not only the heart, but blood donations, as well!
There are multiple blood drives each month at various organizations and offices. To find a blood drive near you, please visit eSource > Departments > Blood Drive.
For more information, please contact Melanie Duncan at melanie.duncan@wellstar.org
At the March and April CVM blood drives, several doctors in the practice were present and donated blood. This shows that CVM physicians have a passion for not only the heart, but blood donations, as well!
There are multiple blood drives each month at various organizations and offices. To find a blood drive near you, please visit eSource > Departments > Blood Drive.
For more information, please contact Melanie Duncan at melanie.duncan@wellstar.org
WellStar Diabetes Services
WellStar’s Diabetes Services provides a nationally recognized educational program for our diabetes and pre-diabetes population. The diabetes team has registered dietitians and registered nurses, certified in diabetes education (CDE), a licensed master of social work and -support staff. Outpatient classes are taught at WellStar Kennestone, Douglas and Paulding hospitals and soon-to-come WellStar Health Park locations. Free support groups are available in multiple locations throughout the community. To reach any member of this team, or to refer a patient, call 770-793-7828.
WellStar Diabetes High Risk Disease Management program is a free telephonic program for any patient with an A1C > 8 percent, who has either WellStar Humana or Medicare insurance, and a WellStar physician. The disease management team is staffed by a registered nurse CDE and a licensed master of social work. To reach anyone on this team, or to refer a patient, call 770-793-7823.
WellStar Diabetes Inpatient Education is available at WellStar Cobb and Kennestone hospitals. The staff is comprised of registered nurse CDEs. In addition to educating high risk patients at bedside, the role of the inpatient educators is to promote and administer the system hospital glycemic initiatives. To reach a member of the WellStar Cobb Hospital team, call 770-732-4119.To reach a member of the WellStar Kennestone Hospital team, call 770-793-7810 or 770-793-7836.
WellStar has diabetes teams at all facilities whose focus is to drive and improve the system’s glycemic initiatives. The teams work to improve patient care by promoting best practice through the utilization of the Zynx order sets to standardize care. Kimberly Roberts facilitates the diabetes team and can be contacted at 770-793-7829 or kimberly.roberts@wellstar.org.
Visit the department website on either www.wellstar.org or eSource > Departments > Diabetes Services for further information.
WellStar Diabetes High Risk Disease Management program is a free telephonic program for any patient with an A1C > 8 percent, who has either WellStar Humana or Medicare insurance, and a WellStar physician. The disease management team is staffed by a registered nurse CDE and a licensed master of social work. To reach anyone on this team, or to refer a patient, call 770-793-7823.
WellStar Diabetes Inpatient Education is available at WellStar Cobb and Kennestone hospitals. The staff is comprised of registered nurse CDEs. In addition to educating high risk patients at bedside, the role of the inpatient educators is to promote and administer the system hospital glycemic initiatives. To reach a member of the WellStar Cobb Hospital team, call 770-732-4119.To reach a member of the WellStar Kennestone Hospital team, call 770-793-7810 or 770-793-7836.
WellStar has diabetes teams at all facilities whose focus is to drive and improve the system’s glycemic initiatives. The teams work to improve patient care by promoting best practice through the utilization of the Zynx order sets to standardize care. Kimberly Roberts facilitates the diabetes team and can be contacted at 770-793-7829 or kimberly.roberts@wellstar.org.
Visit the department website on either www.wellstar.org or eSource > Departments > Diabetes Services for further information.
Friday, April 27, 2012
May CME Events
- Breast Cancer Tumor Board: May 2, 9, 23 and 30; 7 a.m.; Post Stat Cancer Clinic; WellStar Kennestone Hospital
- Cancer Conference (TB): May 2, 9, 16, 23 and 30; 12 p.m.; Wisteria/Jasmine Room; WellStar Cobb Hospital
- Cancer Conference (TB): May 11 and 25; 7 a.m.; Azalea/Camellia Room; WellStar Kennestone Hospital
- GI Tumor Board: May 3, 17 and 24; 7 a.m.; Azalea/Camellia Room; WellStar Kennestone Hospital
- Kennestone Surgical M&M: May 30; 7:30 a.m.; Azalea/Camellia Room
- Neuroradiology/General Neurology Patient Care Conference: May 2; 7 a.m.; Camellia Room; WellStar Kennestone Hospital
- Neurosciences Conference: May 2, 9, 16, 23 and 30; 7 a.m.; Azalea/Camellia Room; WellStar Kennestone Hospital
- Pain Management - An Interdisciplinary Practice; May 16; 8:30 a.m. - 4:30 p.m.; WellStar Development Center; Lunch is included; Call 770-956-STAR (7827) to register
- Primary Care Update Course: Rheumatology; May 5; 7:30 a.m. - noon; WellStar Development Center; Breakfast included; Call 770-22-MYCME (69263) to register
- Safety First Recertification – Douglas: May 16; 6 p.m.; Board Room; WellStar Douglas Hospital
- Safety First Recertification – Kennestone: May 18; 10:30 a.m.; Administrative Conference Room; WellStar Kennestone Hospital
- Thoracic Clinic: May 2, 9, 16, 23 and 30; June 6, 13, 20 and 27; 5 p.m.; Post Stat Cancer Clinic; WellStar Kennestone Hospital
- Trauma Grand Rounds: May 31 and June 28; 7 a.m.; Auditorium; WellStar Kennestone Hospital
- Wound Case Conference; May 4; 12 p.m.; Auditorium; WellStar Cobb Hospital
Thursday, April 26, 2012
Complete the 2012 Medical Staff Partnership Survey by May 29
The FY 12 Medical Staff Partnership will be available through May 29, 2012.
This survey provides an opportunity for you to share feedback and identify areas for further improvement. Once again, Press Ganey Associates, Inc. will administer the survey and individual responses will be confidential. Facility and System results will be available on June 25, 2012 and will compare WellStar to national benchmarks. This survey includes both physicians and advanced practice professionals for each facility.
You should have received one survey from the location of your greatest activity. Additional surveys from other facilities may be requested. The survey can be completed online or by paper and should only take 10-15 minutes to complete.
This survey provides an opportunity for you to share feedback and identify areas for further improvement. Once again, Press Ganey Associates, Inc. will administer the survey and individual responses will be confidential. Facility and System results will be available on June 25, 2012 and will compare WellStar to national benchmarks. This survey includes both physicians and advanced practice professionals for each facility.
You should have received one survey from the location of your greatest activity. Additional surveys from other facilities may be requested. The survey can be completed online or by paper and should only take 10-15 minutes to complete.
The Joint Commission Certified Total Joint Program
Written by Stan Dysart, M.D., M.B.A., and Stephen Kim, M.D., co-chairs of the Total Joint Program at WellStar Kennestone Hospital
No one needed to tell Jerry Niemeyer about the pain and disability associated with knee arthritis. An active individual, Jerry’s knee pain had progressed to the point that by the time he finished a round of golf, he could hardly get out of the cart.
Jerry had joined one of the 46 million Americans affected by arthritis. That number is expected to grow to at least 67 million by 2030. The number of individuals undergoing total hip or knee arthroplasty is expected to skyrocket as well.
The arthroplasty experience at WellStar Kennestone Hospital has mirrored this nationwide trend and necessitated the creation of a comprehensive Total Joint Replacement Program.
No one needed to tell Jerry Niemeyer about the pain and disability associated with knee arthritis. An active individual, Jerry’s knee pain had progressed to the point that by the time he finished a round of golf, he could hardly get out of the cart.
Jerry had joined one of the 46 million Americans affected by arthritis. That number is expected to grow to at least 67 million by 2030. The number of individuals undergoing total hip or knee arthroplasty is expected to skyrocket as well.
The arthroplasty experience at WellStar Kennestone Hospital has mirrored this nationwide trend and necessitated the creation of a comprehensive Total Joint Replacement Program.
New WellStar Medical Group April Providers
Click "Read more>>" to view WellStar Medical Group providers who joined WellStar in April.
Wednesday, April 25, 2012
Bud Zborowski Named Vice President of WellStar Health Park Operations
C.A. “Bud” Zborowski has joined WellStar as vice president of Health Park Operations. His responsibilities will include day-to-day operations, ensuring customer-focused service and the financial leadership of WellStar Health Parks. Bud will report to Robert Jansen, M.D., Executive Vice President WellStar Medical Group President.
Most recently, Bud was a principal in the Garfield Park Group, which works with healthcare companies to address market development and business growth. He brings to WellStar significant experience in development imaging centers and outpatient care services. During his 30 plus year career, he has held a number of leadership roles in healthcare industry companies including Polycom, Inc., Neotonus, Inc., Cornerstone Health Management, Health Images, Inc., American Medical Buildings and Tenet Healthcare.
Most recently, Bud was a principal in the Garfield Park Group, which works with healthcare companies to address market development and business growth. He brings to WellStar significant experience in development imaging centers and outpatient care services. During his 30 plus year career, he has held a number of leadership roles in healthcare industry companies including Polycom, Inc., Neotonus, Inc., Cornerstone Health Management, Health Images, Inc., American Medical Buildings and Tenet Healthcare.
WellStar Physician Leadership Academy Graduates Third Class
On March 27, 25 physicians, physician assistants and nurse practitioners graduated from WellStar’s Physician Leadership Academy. They comprise the third class, bringing the total number of graduates to 98 since the Academy’s inception in 2010.
The Academy is a unique educational experience, providing participants with graduate-level leadership and business instruction. A collaboration between WellStar and the Coles College of Business at Kennesaw State University, the Academy brings business acumen, communication skills, leadership skills and team training to physicians and advanced practice professionals. Participants spend 10 Saturdays over seven months with Coles faculty and WellStar senior leaders improving their ability to serve key medical staff and System roles across WellStar.
The Kouzes and Posner tenets of leadership are used as a foundation for the program. Participants learn to “model the way, inspire a shared vision, challenge the process, enable others to act and encourage the heart.” Participants use a Leadership Practices Inventory to assess their current levels of leadership performance and chart a path for improvement. They learn that self-knowledge is a key to high-level performance. Consistent, world-class performance requires attention to fitness, nutrition, rest and attitude. They learn that good communication requires listening and noticing much more than speaking.
During the final session of the program, the group participates in a healthcare business simulation where they compete with each other to use resources, manage growth and leverage quality to provide world-class care in a successful business model.
Sept. 1 is the application deadline for the next Academy, which begins Sept. 15. For more information, contact Don Campbell, M.D., at don.campbell@wellstar.org or visit the Physician Leadership Academy under the Organizational Learning tab on eSource.
The Academy is a unique educational experience, providing participants with graduate-level leadership and business instruction. A collaboration between WellStar and the Coles College of Business at Kennesaw State University, the Academy brings business acumen, communication skills, leadership skills and team training to physicians and advanced practice professionals. Participants spend 10 Saturdays over seven months with Coles faculty and WellStar senior leaders improving their ability to serve key medical staff and System roles across WellStar.
The Kouzes and Posner tenets of leadership are used as a foundation for the program. Participants learn to “model the way, inspire a shared vision, challenge the process, enable others to act and encourage the heart.” Participants use a Leadership Practices Inventory to assess their current levels of leadership performance and chart a path for improvement. They learn that self-knowledge is a key to high-level performance. Consistent, world-class performance requires attention to fitness, nutrition, rest and attitude. They learn that good communication requires listening and noticing much more than speaking.
During the final session of the program, the group participates in a healthcare business simulation where they compete with each other to use resources, manage growth and leverage quality to provide world-class care in a successful business model.
Sept. 1 is the application deadline for the next Academy, which begins Sept. 15. For more information, contact Don Campbell, M.D., at don.campbell@wellstar.org or visit the Physician Leadership Academy under the Organizational Learning tab on eSource.
New WellStar Cobb Hospital President
Kem Marshall Mullins joined WellStar on April 23 as Senior Vice President and WellStar Cobb Hospital President. In this position, he will be responsible for day-to-day operations and strategic planning for WellStar Cobb Hospital. Most recently, Kem served as chief executive officer for Tenet Healthcare Corporation’s Saint Francis Hospital – Bartlett, a 156-bed medical/surgical hospital in Memphis, Tenn. During his time at Saint Francis, he achieved 5-Star patient satisfaction scores for four years running, improved physician satisfaction, lowered infections rates and improved financial performance at the hospital.
He brings more than 16 years of hospital administration experience including serving as chief operating officer for Atlanta Medical Center and Tenet Healthcare’s Regional Medical Center in Jonesboro, Ark. He also was associate administrator at University Medical Center in Lebanon, Tenn., and Williamson Memorial Hospital, in Williamson, W. Va. Kem has a bachelor’s degree in healthcare administration from Marshall University in Huntington, W.Va., and a master’s degree in finance from Morehead State University in Morehead, Ky.
He brings more than 16 years of hospital administration experience including serving as chief operating officer for Atlanta Medical Center and Tenet Healthcare’s Regional Medical Center in Jonesboro, Ark. He also was associate administrator at University Medical Center in Lebanon, Tenn., and Williamson Memorial Hospital, in Williamson, W. Va. Kem has a bachelor’s degree in healthcare administration from Marshall University in Huntington, W.Va., and a master’s degree in finance from Morehead State University in Morehead, Ky.
WellStar Introduces a Technology-Enabled Physician Contact Service
WellStar is pleased to announce a new physician-centric communications service, PerfectServe, designed to help you save time, improve your personal efficiency and enhance the coordination of care. PerfectServe allows you to selectively filter and control the clinical communications you receive, based upon your workflow, call schedules and individual contact preferences.
With PerfectServe, you designate your preferred mode of communication (pager, mobile phone, text message, etc.) depending on the time of day, caller (nurse or colleague), and/or reason for call (consult, new admission, etc.). It ensures you are contacted by nurses and your colleagues according to your precise instructions.
When PerfectServe is implemented, you will enjoy:
ACTION REQUESTED: To get started, please submit your contact preferences by Monday, May 7. To make this task easy, simply visit www.perfectserve.com/ws; registration should take you less than 10 minutes.
PerfectServe representatives will be onsite April 30-May 4 to answer questions and help you set up your contact profile. E-mail von@perfectserve.com to schedule a one-on-one consultation.
With PerfectServe, you designate your preferred mode of communication (pager, mobile phone, text message, etc.) depending on the time of day, caller (nurse or colleague), and/or reason for call (consult, new admission, etc.). It ensures you are contacted by nurses and your colleagues according to your precise instructions.
When PerfectServe is implemented, you will enjoy:
- Fewer unnecessary interruptions.
- Fewer lost and delayed messages.
- Increased communications accuracy and reliability.
- Easy, direct physician-to-physician contact—a vital tool in building a culture of safety and high-quality care.
ACTION REQUESTED: To get started, please submit your contact preferences by Monday, May 7. To make this task easy, simply visit www.perfectserve.com/ws; registration should take you less than 10 minutes.
PerfectServe representatives will be onsite April 30-May 4 to answer questions and help you set up your contact profile. E-mail von@perfectserve.com to schedule a one-on-one consultation.
WellStar Kennestone’s New Graduate Nurse Pipeline Program A Major Success
Nationally, turnover rates for nurses are high during their first year of work after graduating from nursing school – from 30 to 60 percent. As these numbers show, the transition from school to work is often challenging. WellStar Kennestone Hospital is successfully reversing that trend, thanks to its New Graduate Nurse Pipeline Program.
In August 2010, WellStar Kennestone implemented a structured orientation process, specific to specialty areas. The onboarding program varies in length (from 12 to 24 weeks) depending on specialty.
According to Lisa Pruner, Pipeline nurse practice specialist, and Donna Johnson, Pipeline assistant nurse manager, three new graduate cohorts have successfully been onboarded with retention rates from 93 to 98 percent.
“Orientation times have been reduced while protecting the quality of nursing bedside training,” said Pruner.
More than $1.2 million has been saved thanks to the reduced orientation times and low turnover rates.
“Most importantly, we’ve motivated our new graduate nurses, and formed collaborative relationships with unit managers, educators, preceptors, nursing leaders and clinical nurse/nurse practice specialists,” added Pruner and Johnson.
As a result of the program’s success, WellStar Kennestone is piloting an onboarding process for experienced RNs.
In August 2010, WellStar Kennestone implemented a structured orientation process, specific to specialty areas. The onboarding program varies in length (from 12 to 24 weeks) depending on specialty.
According to Lisa Pruner, Pipeline nurse practice specialist, and Donna Johnson, Pipeline assistant nurse manager, three new graduate cohorts have successfully been onboarded with retention rates from 93 to 98 percent.
“Orientation times have been reduced while protecting the quality of nursing bedside training,” said Pruner.
More than $1.2 million has been saved thanks to the reduced orientation times and low turnover rates.
“Most importantly, we’ve motivated our new graduate nurses, and formed collaborative relationships with unit managers, educators, preceptors, nursing leaders and clinical nurse/nurse practice specialists,” added Pruner and Johnson.
As a result of the program’s success, WellStar Kennestone is piloting an onboarding process for experienced RNs.
Paulding VIP Program
Written by Beth Morrow, RN, Transformation Consultant
As we are beginning to construct the new WellStar Paulding Hospital Replacement facility, one of our guiding principles is to achieve our purpose in creating a holistic environment that is the heart of the community. The Very Important Patient (VIP) program was initiated to build a program that creates, for all patients and families, an experience of welcome, rest and healing.
The evidence on the benefits of healing environments is becoming clear, and we feel that it is important to support the patient as a whole individual (mind, body and spirit). As we move to the new facility, it grants us the opportunity to make the patient and family experience more meaningful by focusing on safety, healing and compassionate care. The processes that we create today will move us in that direction.
The VIP program will create opportunities for patients and families to be part of the healthcare team by allowing them additional choices while hospitalized. In order to achieve optimal health and healing, the program will focus on healing for the whole person. Currently, the program includes: hand therapy, foot massage, back rubs and music therapy. As part of our program, we are training volunteers so they can offer these services in addition to our staff.
WellStar's Hospitalist Program
Dr. Akopov is board certified in internal medicine. He received his medical degree from Tbilisi (Republic of Georgia) Medical Institute and completed his residency in internal medicine at Emory University Hospital.
Strategic Priorities
Growth- WellStar currently has 46 hospitalists at WellStar Cobb, Douglas, Kennestone and Paulding hospitals (39 physicians, six advanced practice professionals and one RN). The program hopes to expand by more than 30 percent in the next few months, and also will extend its round-the-clock coverage to WellStar Paulding Hospital by July 1. By having 24/7 coverage at Paulding, we will keep patients closer to home as well as drive the need for specialists to start seeing patients at Paulding. This will help build the hospital image in advance of the new hospital opening.
“We are uniquely positioned to impact patient outcomes – from quality and safety to efficiency and patient satisfaction – since we have a 24-hour presence in the hospital,” said Dr. Akopov. “We build relationships with nurses, care coordinators and consultants, and serve as ‘captain of the ship,’ ensuring timely and coordinated care delivery.”
Transitions of Care – WellStar also will aim to provide a seamless flow of information during and after patient discharge. “WellStar hospitals will ‘own’ certain patient outcomes, such as re-admissions, for 30 days after discharge,” explained Dr. Akopov. “We would like clinical staff at each hospital to schedule appointments for patients with their primary care physicians (PCPs) before discharge and make follow-up calls to ensure patients are compliant with their care plans. We also will strengthen communication with PCPs. All these efforts will improve patient outcomes.”
Olatunde Idowu, M.D. Earns Fellow in Hospital Medicine Designation
Olatunde Idowu, M.D. of WellStar Cobb and WellStar Paulding's Hospital Medicine Service has earned the Fellow in Hospital Medicine (FHM) designation for the Society of Hospital Medicine (SHM). He was inducted as a fellow at SHM's annual meeting in San Diego, Cali. on April 3, 2012.
The FHM credential is a key component in professional development for hospitalists. To be designated as a FHM, a hospitalist must:
- Serve as a hospitalist for at least five years
- Be a member of SHM for at least three years
- Demonstrate their dedication to quality, process improvement, commitment to organizational teamwork, leadership, and lifelong learning
New Medical Staff as Approved at the April Governing Board Meeting
| Name | Specialty | Group Name | Appointment | Current Staff Membership |
| Conde, Jenifer D., M.D. | Obstetrics and Gynecology | Northwest Women’s Care | KH, WH, WMG | |
| Dagnew, Elias, M.D. | Cyberknife Stereotactic Radiosurgery | Georgia Brain and Spine Center | KH | |
| Dilts, Samantha L., M.D. | Pediatrics ER | The Bortolazzo Group, LLC | CH, KH | |
| Dyer, Divina N., M.D. | Family Medicine | Caduceus Occupational Medicine | DH | |
| Hoffman, Allen M., M.D. | Internal Medicine | Wellstar Community Clinics | CH,DH | KH |
| Levine, Amy M., M.D. | Pediatrics ER | The Bortolazzo Group, LLC | CH | KH |
| Schaufele, Michael K., M.D. | Pain Medicine | Pain Solutions Treatment Ctrs | KH, WH |
Advanced Practice Professionals
| Name | Specialty | Group Name | Appointment | Current Staff Membership |
| Anyanwu, Justina N., NP | Nurse Practitioner | Paulding Nursing Services | PH, WMG | |
| Brinker, Krystin A., PA | Physician Assistant | Vascular Surgical Assoc., P.C. | CH, KH | |
| Crownover, Julie D., PA | Physician Assistant | Emory Healthcare | KH | |
| Little, Kylie R., PA | Physician Assistant | The Bortolazzo Group, LLC | CH, DH, KH, PH | |
| Simms, Eddie L., PA | Physician Assistant | Cardiovascular Medicine | CH, DH, KH, WMG | |
| Von der Schulenburg, Amanda G., PA | Physician Assistant | VDS Surgical Assistants | CH | KH, WH |
WellStar’s Diabetes Services
Self-management education is a vital part of caring for people with diabetes. Almost 80,000 people diagnosed with diabetes live in WellStar’s market area, and the CDC estimates another 26,000 people in this area have diabetes, but have not been diagnosed.
The 2011 Annual Report and 2012 Program outline Diabetes Services’ commitment to create and continue to deliver the highest quality diabetes education, management and service to individuals in our communities. Approximately 2,500 people with diabetes attended comprehensive self-management classes and annual refresher classes in 2011. Many more participated in pre-diabetes, gestational, high-risk disease management, weight management programs and support groups.
Taking part in WellStar’s diabetes services has many benefits for both the participants and the System:
For a copy of the 2011 Annual Diabetes Self-Management Education Review and 2012 Program Plan, please contact Amanda Hextell at 770-793-7821 or amanda.hextell@wellstar.org.
The 2011 Annual Report and 2012 Program outline Diabetes Services’ commitment to create and continue to deliver the highest quality diabetes education, management and service to individuals in our communities. Approximately 2,500 people with diabetes attended comprehensive self-management classes and annual refresher classes in 2011. Many more participated in pre-diabetes, gestational, high-risk disease management, weight management programs and support groups.
Taking part in WellStar’s diabetes services has many benefits for both the participants and the System:
- There was 70 percent reduction in hospitalizations and the A1C reduction for WellStar as a system continued to trend below the 7 percent recommendation of the American Diabetes Association.
- Participants expressed their approval of the program with a 97 percent highly-satisfied evaluation.
- Scores in the top 95th percentile of the Gallup employee engagement survey confirm that the staff members enjoy their work and working environment.
For a copy of the 2011 Annual Diabetes Self-Management Education Review and 2012 Program Plan, please contact Amanda Hextell at 770-793-7821 or amanda.hextell@wellstar.org.
WellStar Health System’s Gold Standards of Clinical Documentation Improvement
General and Gastrointestinal-Specific Clinical Documentation Tips
WellStar Health System’s Clinical Documentation Improvement (CDI) Program 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.
As part of the program’s ongoing efforts, the CDI team offers specific tips monthly from the Program’s Gold Standards of Clinical Documentation Improvement.
General Tips:
WellStar Health System’s Clinical Documentation Improvement (CDI) Program 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.
As part of the program’s ongoing efforts, the CDI team offers specific tips monthly from the Program’s Gold Standards of Clinical Documentation Improvement.
General Tips:
- Coding rules disallow the use of up and down arrows to indicate a diagnosis (e.g., ↑K cannot be used to code hyperkalemia; the provider must document the condition.)
- When using abbreviations, the diagnosis is best captured when the condition is written out in full at least one time in the record (e.g., AKI could indicate Acute Kidney Injury or Acute Kidney Insufficiency).
- Diagnoses: indicate if acute or chronic
- Link diagnosis with manifestations (i.e., acute hepatitis C with hepatic coma)
- GI bleed: indicate if with or without hemorrhage, even if suspected because no longer bleeding at time of scope
- Link ulcer: indicate if with or without hemorrhage, obstruction or perforation
- Link ulcer with site: esophageal, peptic, duodenal. Be as specific as possible.
- Specify location of calculus (i.e., gallbladder, bile duct, etc.)
- Esophageal varices: link underlying condition, if known (i.e., cirrhosis, portal hypertension)
- Gastroenteritis: identify infectious organism (i.e., candida, bacterial, virus)
- Alcohol-related conditions: (i.e., dependence, abuse/chronic, withdrawal delirium, delirium tremens, withdrawal) OR current alcohol state: alcoholism, abuse or history of
- Electrolyte imbalance (i.e., hyper/hyponatremia, hyper/hyp kalemia, acidosis, alkalosis, mixed acid base balance disorder)
- Nutritional state: if malnourished, indicated mild, moderate or severe or cachexia
- Hemorrhage/bleed: indicate if acute or chronic
***GI bleed/hemorrhage is not synonymous with acute blood loss anemia***
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