This week is CDI Week, an annual celebration of Clinical Documentation and Improvement.

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

CDI is all about empowering clinicians to deliver safer care to every patient by creating a documentation culture that reflects the clinical truth.

It’s about bridging the gap between clinicians and our clinical coders so that the clinical data is reflective of the patient’s inpatient hospital stay and that Northern Health receives optimised reimbursement under the National Activity Based Funding model. Data-driven decision making relies heavily on complete and accurate clinical documentation and clinical coding, so it is imperative to get it right the first time.

Northern Health’s CDI program began in late 2017 with the aim of improving the clinical documentation in real-time, rather than waiting for our coding auditors to feed back the documentation gaps to specialties retrospectively, often months after patient’s discharge.

The team consists of Mary Kouvas, Clinical Documentation Integrity Coordinator, and Diana Villalta, Clinical Documentation Specialist (CDS).

“Without CDI, a patient’s health and safety is potentially at risk and Northern Health may not be receiving optimised reimbursement for the care they deliver,” Mary said.

“Research and planning for the future is affected as well. Remember the saying – “Rubbish in, rubbish out” – We ensure the documentation in the healthcare record is complete and accurate, to enable the extrapolation of valuable data.”

On a daily basis, Mary and Diana review current inpatient notes for patients who are planned for discharge on the same or following day, while also looking for documentation gaps.

Since November 2022, they have been using Medtasker to better engage with clinicians and send the documentation gaps called CDI queries.

“Since its implementation, we have seen the response rate to these CDI queries increase from 35 per cent on average to above 90 per cen – an extraordinary improvement.” Mary said.

“Using Medtasker has been a game-changer, not only for Northern Health but for the wider Australian CDI community. We were fortunate to present our success story at two conferences in Australia last year and received much interest in this innovative approach to CDI.”

With the implementation of the Electronic Medical Record (EMR) in September last year, the CDI team is now able to work remotely from either an onsite office or from home.

“Going fully electronic means we can now leave the clinical ward areas for clinicians and patients which is how wards were intended to be used, without affecting clinician engagement. The benefits of using Medtasker is that the clinician can respond to the CDI query at their earliest convenience, without impacting patient care,” Mary said.

“By receiving the CDI query in real-time, the clinician is able to update the documentation in the EMR, notify the CDS, the CDS can check to see if the documentation change is sufficient for coding, resulting in a complete and accurate account of the patient’s episode of care, whilst optimising NWAU.”

“A very effective and efficient process where our clinicians are able to continuously learn and document better.”

“We are looking forward to the future and how we can work with AI to enhance the process of good documentation practices. Watch out!”

Featured image: Diana Villalta CDS and Mary Kouvas CDI Coordinator.