I get your clinical providers. I anticipate and answer their questions. I know how to overcome their resistance and concerns. I get how hard it is to document in the EMR.
I speak all dialects of doctor – I know how unique and different every specialty is. I know what conditions they see regularly, what procedures they are likely to do, and which diagnoses they are likely to be underdocumenting.
I have given hundreds of presentations on Quality, CDI, and ICD-10 to providers, CDI specialists, and coders, including at ACPA’s NPAC, National ACDIS, AHIMA, NOHIMA, OrHIMA, and NODS.
You get me in a room with your providers (they don’t even have to be willing participants), and I can teach them quality, CDI, and ICD-10
I don’t just teach; I inspire. Your providers will understand WHY this is important, WHAT they need to do, and HOW to do it.
My philosophy is if your providers understand why they need to document differently, they will choose to document better. It is in their best interest, their practice’s best interest, but most importantly, it is in the best interest of their patients.
Unfortunately, when we implemented the electronic medical record, we lost some of the cognitive process. Everyone agrees that it is high time to return to the practice of thinking before documenting. I am of the opinion that Clinical Documentation Integrity not only improves quality metrics, but, by improving clinical communication, it actually improves the quality of care we provide to patients. And THAT should be everyone’s primary goal.