ICD-10 Advice From Kelli Estes

CDI Review Notes – How much is too much?

Compiling a “CDI version” of the documented H & P is too much!

Inevitably, CDSs need to make notes to prompt their thoughts about the cases they review, but there is much better use of time and productivity by honing in on what lacks in documentation rather than copying what is already well stated.

In defense of a CDS “newbie”, writing down more clinical content in the review notes is understandable and certainly expected while training. However, as the CDS matures, irrelevant content will become much clearer thus resulting in less daily review notes.

The CDS must gain perspective regarding the intent of review notes. The logic behind review notes is to assist any CDS with being more efficient in their work not a burdensome process eating away excessive amounts of time. In reality, CDI review notes are intended to serve as a quick reference to the potential need for pursuing improved documentation via physician clarifications.

It is important to note that the vast majority of CDSs entering the marketplace are nurses. Nurses are trained to give and receive shift reports encompassing a thorough overview of the patient’s active medical problems as well as past medical history, treatments, labs, x-rays, diet, activity, etc. This is part of a process embedded into the standard training for nurses. As a nurse, it is difficult to embrace different methods of note taking as it relates to the world of CDI. Like any learned process, it is difficult to make changes.

Additionally, nurses are not coders. However, they need a “working knowledge” of coding to do their job well. Because of this, they sometimes feel the need to write more than what’s necessary. It helps to have a strong “working knowledge” of coding to understand how certain type notes will help compliment their work when identifying the need to obtain more specific physician documentation.

But, in the end, it would be most helpful to just keep it simple and review more cases!
Kelli Estes, RN, CCDS

http://cditips.com/excessive-note-taking-less-reviews-decreased-productivity/