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Christopher Thuer, Manager of Clinical Documentation Improvement (CDI) at Northside Hospital in the Atlanta, GA area shares how CDI is positively impacting staff and patients across healthcare.
Without technology, CDI programs are heavily dependent on human capital to sift through clinical notes for proper quality, coding, and billing. Christopher explains how a detailed note may not contain particularly accurate or complete diagnoses, leaving coders short of the information they need for billing. This is where the addition of technology complements and enhances staff workflow.
8:47 “It gives us everything at our fingertips that we need to do a thorough review of the chart and to have the discussions with the correct information at the time that we need to have them.”
Working with technology streamlines processes, minimizes errors, and allows everyone on staff to spend more time focusing on the patient.
Christopher reports that providers often credit CDI specialists with having their backs and saying things like:
13:02 “It’s great to have your eyes on these charts with us because you see things we may have missed because we’re so caught up in other things - things that are going on at the bedside with the patient. So you have our backs essentially.”
He shares a story of how a CDI specialist was able to bring a few details to the physician’s attention about a patient’s chart, which allowed the care team to catch sepsis early enough to avoid a poor outcome for the patient.
CDI specialists are part of the care team and help drive quality care through better documentation.
CDI is not a new frontier for nursing. What’s new is using AI to amplify the intelligence of the CDIS team, getting them back to the bedside so they can concurrently improve clinical documentation as it happens.
Christopher highlights how the role of a CDI specialist is an opportunity for nurses. They can bring their skills and what they have learned at the bedside and use them in a new way, while still positively impacting patient care.
