David Newton, a Clinical Documentation Manager, and Michelle Brooks, a Corporate Director of Case Management in Clinical Documentation Improvement (CDI) at Baptist Health Care, discuss the importance of accurate and timely clinical documentation and how they have seen CDI transform hospital and patient outcomes.
Specialists in CDI help support ongoing education and communication between coding professionals creating medical records and physicians. David shares an example from his experience where his team realized that the Emergency Room department wasn’t capturing the Glasgow Coma Scale consistently. This identification led them to improve their charting which had exponential benefits.
7:36 “We really educated them. We helped them see how the nursing staff, the direct care staff, how their charting was going to impact this case overall… their opportunity to see how what they’re doing impacts the bigger picture.” - David
9:31 “Over the course of our program, we’ve seen our impact number go from 30% down to about 20-15% due to physicians documenting so well that we do not have to query on certain encounters.” - Michelle
CDI programs have an even deeper impact when all of the staff is on board. Michelle and David highlight how these leaders across departments play an important role in CDI implementation and performance.
David shares a few stories of how he has seen CDI specialists directly impact patient care by spotting mistakes, errors, or resolving questions in their medical records. Simultaneously, the CDI specialists are able to support, protect, and help doctors and nurses provide the best care for their patients.
Michelle adds that looking at the peer benchmarks, quarterly reviews, and data and metrics on hospital performance once CDI program is implemented is always encouraging. The numbers reveal how better documentation and accuracy are improving performance.
20:18 “We are keeping the patient at the center of healthcare. Great clinical documentation equals out to great quality care and ultimately the patient is benefitting from the whole program.” - Michelle
