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Janice Cromer is a System Director of Clinical Documentation Integrity (CDI). In her role, she helps set standards of practice, guidelines, and productivity within facilities. In this episode, we discuss how Advanced CDI supports doctors and nurses in providing better patient care.
Janice shares how CDI used to be utilized to improve financial outcomes when she first started. Today, it’s exciting to see how it can be a tool for improving patient outcomes as well, and the value that it brings to patients and facilities.
The term Advanced Practice CDI highlights this change from financially driven to quality-driven CDI. Advanced Practice CDI requires more advanced, detailed documentation of a patient’s health and care they receive. Clinical Documentation Specialists (CDS) now look beyond the financial aspect of a patient’s visit and focus on catching opportunities in documentation for secondary diagnoses and present on admission symptoms.
A favorite success story of Janice’s was when she was building a new CDS team at a hospital. There were only five on the team, but they built out a strong set of standards, processes, and goals. Once they implemented these checkpoints, they saw improvements in the following areas:
1. Their mortality rate became more accurate and dropped from 1.7 to 0.8. Today, it has decreased to 0.62.
2. Increased collaboration between the coding team and CDS team which impacted the hospital’s Leapfrog and CNS star ratings.
She also emphasizes how a CDS can bring a new perspective when searching for the root cause of a patient’s symptoms. A CDS is able to really dig into a patient’s chart, read between the lines of the physician’s notes, and piece the puzzle together.
13:01 “We’re not caregivers or care providers, we can kind of stand outside that box and observe and look at all of the details and sometimes maybe have an ah-ha moment and share it with someone where it would make a difference in a patient’s life.”
This accuracy and detail is so important when there are a number of professionals looking at a patient’s chart. The more accurate the chart is, the better clinical picture the rest of the team will see.
Janice encourages those interested in CDI to become certified as a CDS, focus on quality care, and never be afraid to ask for clarifications. It might just save a patient’s life.
