CDI and Coding Professionals: Indispensable Links in the Chain of Care

By Brian Murphy

CDI professionals (and clinically astute coders) can positively impact patient care.

How?

By being mindful during their chart reviews, noticing documentation discrepancies, and bringing them to the attention of the care team.

On the latest episode of Off the Record, Lynne Spryszak, RN, CCDS, gave a couple wonderful examples.

Lynne was re-reviewing a hospitalized patient’s record and observed a urine culture had come back with a positive result for an infection. She then reviewed the medication list and noted nothing had been prescribed for treatment. Lynne alerted a nurse with the results; the nurse contacted the treating physician who began a course of antibiotics.

CDI work leading to a direct change in patient treatment.

Patient safety remains an issue in our nation’s hospitals. Diagnostic error harms nearly 800,000 U.S. patients annually, according to one study (see reference below).

You can see how documentation mistakes can happen, leading to patient harm.

Incredibly busy, burned-out physicians copy/pasting the same note from the day prior without making updates. A suspected diagnosis is ruled out, but gets carried forward in the record, leading to inappropriate treatment and discharge instructions.

Poor documentation can lead to other, non-health related but nevertheless detrimental impacts. For example, a documented “possible” seizure disorder (later ruled out) remains in the patient’s health record, leading to loss of a driver’s license. Down the line a patient receives an insurance coverage denial for a “pre-existing condition” that never existed to begin with.

Better technology isn’t always the answer.

A recent article from Healthcare IT News (see link below), describes how a new EHR deployed in the VA led to incorrect medication information. One report described how a veteran was hospitalized after their medication was dropped from the list in the EHR.

If OIG auditors–many of which have no clinical background or training–are flagging these issues, so can you. Sharp-eyed professionals who are in in the medical record every day can play a big role in rectifying these errors.

As Lynne notes in the podcast, the EHR interface on your computer screen, the problem list, the medication list, the progress notes—all represent an actual human being. Take that responsibility seriously.

“We should be mindful that what we do has to be done carefully and mindfully,” she says.

It’s a big part of what makes coding and CDI such great careers: They’re an indispensable link in the chain of care.

References

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