CDI Program Serves as a Bridge to Documentation Improvement

With all the changes in healthcare, and the differences in payment structures, the focus is on quality documentation which affects not only the inpatient setting but outpatient as well. Expanding Clinical Documentation Improvement, CDI, into different areas represents efforts to have a more global view of patient populations and complete and accurate documentation of the clinical picture.

CDI specialists review patient medical records and assess whether all conditions and treatments are documented. This documentation paints an accurate picture of the severity of a patient’s illnesses and risk of mortality. When the documentation is unclear or deficient, CDI specialists prompt (also known as “query”) physicians to provide clarification. CDI specialists serve as the bridge between health information management and clinical staff. They comply with Medicare and/or private payer rules and regulations.

A big Thank You to our very own Clinical Documentation Specialist Marlyn Berry, RN, for all the hard work she has put into this program since its beginning in Massena Memorial Hospital in January 2015.

The program utilizes Berry's extensive medical background, from her 12 years in Medical Surgical, countless hours in the Emergency Room, Intensive Care Unit, Operating Room and Endoscopy to her time as a nursing director.  Her experience plus her training as a CDI specialist  and the use of 14,567 diagnoses codes and 3,882  procedure codes  "paint an accurate picture of the severity of a patients illness and risk of mortality... serving as a bridge between health information management and clinical staff."  

 "Documenting patient care delivery is an integral part of what our caring medical staff, nurses and allied health professionals do every day.  CDI complements the excellent care patients receive as at MMH by insuring an accurate and complete medical record," explained Corporate Compliance Officer, Julie Zyzik, RHIT, CHC, Corporate Compliance Officer, Director Data Integrity. 

John Burnett, MD, Chief of Medicine said, "I think the CDI program has been a very educational program guiding us into the nuances of documentation and starting the CDI program shows how well all of us at Massena Memorial Hospital worked as a team."

Berry collaborates with other professionals in our hospital clarifying records to capture the severity of a patient’s illness.  "Success of our program is based on our collaboration" said Marlyn.   

Zyzik agreed stating, "Expectations have been surpassed due to unyielding support from the hospital board of managers and the hard work and dedication of the MMH medical staff, clinical documentations specialist Marlyn Berry and inpatient coder Stasha Blanchard." 

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February 2017

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