Try a “yes, and” approach when changing provider documentation habits

I love this “yes, and” approach recommended by my current Off the Record podcast guest, Kalee Vincent.

Many physicians prefer (and need, for quality reporting purposes) the New York Heart Association (NYHA) Classification for their heart failure patients, for example. But CDI needs acuity and type to satisfy hospital coding and billing.

Instead of thinking in binary “clinical language vs. coding language,” reframe to: Why not both?

Listen to the clip below for more details on how to get both in the record.

Here’s the transcript:

Working with providers I’ve realized, while in this role, that I never really realized before is, providers have so many different requirements for different reasons. I’ll use heart failure as an example.

We know to get it reported on the hospital side to move that CMI and severity of illness within our patient population, we need acuity and type. So maybe acute and chronic systolic heart failure, that’s what we need to move those metrics.

But for STS, the providers need to stay that New York Heart Class. So talking to them, they’re like, we need to state New York Heart Class. And they have so many different requirements and so many different things coming at them for different reasons.

So my advice in that situation is then continue to state your New York Heart Class, but also state acuity and type for us to be able to, show that we have a sick patient, show why the patient was here for 9 days when you know to the outside world maybe with your documentation, it looks like they should have been here for two.

I can imagine maybe someone who’s new to the role or new to CDI might try to say, well don’t do this, do this. But you’re saying, “do both.” If you really want to stick with that criteria that that you love and might be very important to them from the clinical record perspective, continue to use it. But we also need this.

I’ve had some good feedback on this episode. If you haven’t listened, please do so (link to full episode below), and then leave us a 5-star review. It helps others find Off the Record.

Listen to the full episode here: https://www.norwood.com/back-to-documentation-school-lessons-from-cdi-educator-kalee-vincent/