Sharon Krug is the System Manager for the Clinical Documentation Department at TriHealth in Cincinnati, OH. In this episode, we discuss the significance of specific and clear documentation in light of electronic patient medical records, and how CDI impacts a patient’s hospital stay.
Initially, Sharon shares how their CDI team only focused on reviewing traditional Medicare. However, as medicine and reimbursement changed, they expanded to reviewing all payers. This resulted in both positive financial impact and patient outcomes.
4:18 “What we need to do is paint a very accurate picture of how sick the patient is when they get to the hospital and all of the resources that are required to take care of that patient. And so we will go for every diagnosis whether it has a financial impact or length of stay impact just to try to get a very accurate picture of that patient’s care.”
She compares a CDI specialist’s job as looking for a four leaf clover or an easter egg. You have to dig deeper and identify exactly what the doctor means. Often, this requires checking in with the doctor to clarify their diagnosis in order to create an electronic record that is detailed and nuanced.
Electronic medical records allow patients’ medical history and details to transfer to wherever they are receiving care. Having access to these detailed, nuanced records could ultimately impact patient treatment and health outcomes down the road, wherever a patient may be.
From a CDI standpoint, Sharon highlights their focus on using the correct words in order to present accurate coding on a patient’s chart. The precision of language is crucial to strong CDI.
She has seen first-hand how CDI has expanded from serving a financial purpose to creating a better patient diagnosis by focusing on details like:
At TriHealth, Sharon shares how their struggle with malnutrition documentation necessitated a change. She worked with department staff and dietitians to implement another checkpoint to ensure that patients agreed with their physician’s assessment of their health. This helped both patients and the hospital have a more accurate financial relationship.
When she transitioned from working as a nurse to working as a nurse in CDI, Sharon says she was concerned that she might lose some of her nursing skills and expertise, however, she has found that CDI actually increases her level of knowledge as a nurse.
16:05 “I feel like personally, I continue to grow on a regular basis, and professionally, I am doing a wonderful service to the patients whose charts we review.”
Sharon has found that while her direct patient interaction has decreased, her work continues to impact patients directly while working in CDI. One example is when she reviewed a young man’s charts and saw he was at risk for a heart attack. This was not assessed by the doctor until she brought it to his attention, and by catching this detail, they were able to provide critical care.
