Clinical documentation in the healthcare record is vital in planning, resource consumption and improving patient outcomes. It is where our clinical coders abstract the information they need to classify diagnoses and interventions.

Often, the language used for clinical purposes and that required by our clinical coders is different. Clinicians frequently use generalised clinical terms, signs, symbols, and abbreviations. While this is meaningful for communicating between treating healthcare professionals, these terms are not always able to be translated into codes required for reporting and funding or coded to the required specificity that reflects the complexity of the patient. This disconnect can significantly affect the quality of hospital casemix data. If the clinical coding does not fully capture the activity and level of service that was provided, it can result in an under-representation of patient complexity leading to sub-optimal hospital reimbursement and incomplete reporting to external agencies.

Clinical Documentation Improvement (CDI) is the process of reducing the ‘disconnect’ between what clinicians write in the healthcare record and what clinical coders need to produce quality casemix data. It achieves this by placing a Clinical Documentation Specialist (CDS) on the ward to review clinical documentation in a timely manner while the patient is still admitted. CDSs help clinicians to document using a format that is clear, complete, and accurate, to aid with patient management and also to be readily acceptable for clinical coding.

Northern Health implemented a Clinical Documentation Integrity Program in 2018 to facilitate the accurate representation of a patient’s clinical status.

Mary Kouvas,  CDI Coordinator says, “When I graduated back in 1993, Victorian hospitals were transitioning from block funding to an activity-based funding model. My first job was to ensure the clinical documentation was complete and accurate to ensure correct reimbursement. Most of this was done retrospectively, that is, about two weeks post discharge,” says Mary.

At Northern Hospital, Mary and the coding team played an important role in ensuring all patients receiving HiFlow Therapy (HFT) via nasal cannula or prongs were captured in our data to ensure  correct reporting. “By educating clinicians and improving forms, we were able to capture this information better which meant that our data was more reliable. This improvement was also the catalyst in establishing the Respiratory Care Unit at Northern Hospital where our patients are better managed whilst receiving HFT.”

The CDI Team has grown in the past year and now consists of Saja Sammour, Health Information Manager and Diana Villalta, a newly appointed CDS with a background in dietetics and midwifery. “We are excited to welcome Diana to our CDI team as her clinical knowledge and ward experience will complement our knowledge in coding and casemix,” says Mary.

Terri Fiorenza, Director Health Information Services, says Mary and the CDI team are to be congratulated in establishing a successful Clinical Documentation Integrity Program at Northern Health, which continues to grow and improve.

Says Terri, “The team’s presence in clinical areas continues to strengthen the clinicians knowledge and importance of accurate clinical documentation in the healthcare record, not only from a funding reimbursement perspective, but from a qualitative perspective as well.”

Featured image shows from left to right:
Saja Sammour, Health Information Manager; Mary Kouvas, Clinical Documentation Improvement Coordinator and Diana Villalta, Clinical Documentation Specialist.