Clinical Documentation Improvement Key Metrics
There are two types of clinical documentation improvement (CDI) key metrics, strategic and operational. Strategic metrics capture the long-term impact of improvements on case mix index (CMI) or quality ratings. Operational metrics, the subject of this article, measure day-to-day activities of the program that can also have significant impact over time. While specific metrics may vary from hospital to hospital, the key metrics for every CDI program should include the following concurrent measures: 1. Record review rate 2. Physician (or other clinician) query rate Response rate 4. Agreement (or validation) rate .
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Stage Three Electronic Medical Record (EMR) Implementation: Clinical Documentation Improvement Opportunities
According to the Healthcare Information and Management Systems Society’s (HIMSS) definition, stage three transformation means that clinical documentation (vital signs, flow sheets) is required; nursing notes, care plan charting, and the electronic medication administration record (eMAR) system are scored with extra points, and are implemented and integrated with the clinic data depository (CDR) for at least one service or one unit in the hospital. The first level of clinical decision support is implemented to conduct error checking with order entry (drug/drug, drug/food, drug/lab conflict checking normally found in the pharmacy). Some level of medical image access from picture archive and communication systems (PACS) is available for access by physicians via the organization’s Intranet or other secure networks outside of the radiology department confines.
Read Full Article, Rate it or Share Your Comments Clinical Documentation Specialists: Their Interaction with Physicians Should Not Be A Potential Compliance Risk
If you have trained your physicians and staff members appropriately and implemented your program in accordance with solid training guidelines like those presented in the Compelling Case for Clinical Documentation books, the clinical documentation specialist’s (CDS) interaction with physicians should not be a compliance risk. There has been some concern that certain CDS practices such as leading queries or inquiries written on sticky notes, or the physician’s interpretation of the question being asked of her is a compliance risk. Scenarios with the CDS asking the physician if a patient has blood loss anemia, a leading query, are anecdotal examples of potential compliance risks in the interaction between the CDS and the physician. It is unclear whether these scenarios have actually ever occurred, or if they are just worst fears expressed in the form of possible problems. If your organization has implemented initial and continuous physician training, these compliance concerns should never become a reality for you.
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Reader Poll
Visitors were asked the following question and here are the results:
Who teaches your CDI training sessions for physicians? 41.2% - A CDI professional
41.2% - We do not current provide CDI training
11.8% - A physician and a CDI professional
5.9% - A physician
0% - Other Current Poll
My facility currently tracks CDI metrics such as query rate or response rate:
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Did You Know?
Physicians in the CAMP Method training study reported that their most significant documentation concern, prior to training, was their ability to clearly document the clinical significance of abnormal test results. Since Joint Commission and Medicare both require documentation of the clinical significance of abnormal test results, training your physicians using examples of abnormal test results with several different suggestions for documenting the clinical significance of the test [depending, of course, on the individual patient] is a key area for initial, follow-up or refresher training for your medical staff.
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CDI Guidebooks for Managers
 The Manager's Guides to Clinical Documentation is a 3 volume set of guidebooks designed to introduce a facility's management to the concept of clinical documentation and how it can impact an organization. More Information Sample Job Description:
Clinical Documentation Manager Documentation Example:
Internal Medicine Pro-fee Impact Sample Letter from CEO Announcing CDI Program Position CDI as Value-Added Sources for Clinical Documentation Guidance The Patient Record is Your Common Ground with Your Medical Staff The Seven Criteria for High Quality Clinical Documentation  CDmatters.com RSS Feed
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