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Nuance in Healthcare Podcasts: Episode 7

Integrating CDI and electronic medical records for better patient care with Sharon Krug

Episode 7

Episode summary

Electronic medical records and language precision

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.

Overcoming challenges

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.

CDI increases nursing knowledge

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.