This week, we celebrate Clinical Documentation Integrity (CDI) programs at healthcare services around Australia.

Here at Northern Health, it is a time to recognise our CDI professionals and the vital role they play in improving patient safety, enhancing the quality of healthcare data and ensuring the financial sustainability of health services.

Often, the documentation in patient healthcare records makes sense from a clinical care perspective, however, it may be missing key information for our clinical coders. Incomplete documentation can lead to incomplete coded data and subsequently incomplete reporting and funding. The aim of the CDI team is both to address documentation gaps, and also provide real-time feedback to our clinicians so that their notes are complete and accurate for every inpatient encounter every time.

Diana Villalta, Clinical Documentation Specialist, joined the team just over a year ago.

“I come from a clinical background of Dietetics and Midwifery. My fellow CDI colleagues come from a Health Information Management (HIM) background. This mix of clinical and HIM skill sets works well for a CDI team, as we are able to bounce ideas off each other and look at things from different perspectives,” Diana says.

“I enjoyed direct patient contact in my previous roles, however, I have really enjoyed making an impact in other ways whilst still using my previous skills and knowledge. Prior to this role, I knew very little about coding, casemix and funding. I always knew, as a clinician, that documentation was very important, but it has been fascinating to see the process in which the documentation is reviewed, coded and extrapolated for different purposes. I am more aware now of all the dedicated staff who work in HIS and more specifically the CDI and Coding and Casemix teams who work hard to ensure that every inpatient episode is coded accurately to reflect the clinical truth.”

Mary Kouvas, Clinical Documentation Integrity Coordinator, Health Information Services, says, “There are some exciting things on the horizon for CDI here at Northern Health. In particular, we look forward to trialling a digital move in communicating our documentation queries with the doctors, through the use of Medtasker. This will mean moving away from our current paper-based form, which will hopefully improve response rates and decrease retrospective queries, not to mention it being better for the environment! We also look forward to transitioning to the EMR and seeing what challenges may arise in the documentation space.”

Learn more about CDI by participating in the CDI Quiz on the Intranet for a chance to win a hamper!

Picture shows Diana Villalta, Clinical Documentation Specialist.