by Julie Mortley MACN, Clinical Documentation Specialist
As I look back on my nursing career I feel eternally grateful to the profession for the opportunities and experiences it has given me. More than ten years ago I left Australia to work overseas and transitioned into the roles of case management and clinical documentation improvement (CDI). In 2016 I finally returned home and found the Australian health system beginning to take interest in the role of clinical documentation specialists (CDS). Since then hospitals have started to implement CDI programs under the auspices of health information management.
I have a passion for safe, accurate documentation which clearly reflects a patient’s hospital journey. The updated second edition of the National Safety and Quality Health Service (NSQHS) standards by the Australian Commission on Safety and Quality in Health Care (ACSQHC) (2017), (referred to as the Commission from here on in), acknowledges how communication errors can seriously impact and compromise patient safety outcomes and quality of care. CDI is gaining momentum in Australia and this is an opportune time to raise awareness within the profession of a new career pathway for nurses. The role not only allows nurses to make a real difference in the safety and quality arena, it also contributes towards hospitals receiving the correct reimbursement for the resources used to treat patients with complex conditions.
According to Brown (2013, pp10-12) the ideal candidate for the CDS role is “a sharp, analytical nurse with a strong bedside background, a head for business, and a passion for language and precision”. When analysing medical documentation with a clinical eye the CDS is looking for what is not there and recognising what should be there. Experienced nurses know this innately, they have the clinical background to educate and discuss documentation issues with clinicians and positively change patient outcomes.
The CDS role first developed in the United States in 2007 in response to the implementation of the diagnosis related group (DRG) system for reimbursement purposes (Brown, 2013). The role has continued to grow and evolve in the United States, supported by evidence which shows CDS intervention improved the quality and accuracy of clinical documentation for patient management and coding purposes (Buttner et al., 2014). The introduction of CDI in Australia was also spurred by changes to funding models and the introduction of activity based funding, which is reliant on accurately reflecting the patients severity and complexity of illness through correct DRG allocation.
The data for DRG allocation is derived from the patient’s principal diagnosis, additional diagnoses and procedures together with specific demographic data, all of which are sourced from documentation within the clinical record. The diagnoses and procedures are converted into codes from which the patients episode of care is then allocated into a DRG. Each DRG is given a different cost weight, their value is determined by the complexity of diagnoses and procedures. How this is reflected is wholly dependent on the quality of documentation in the clinical record. If diagnoses are missed or not written in specific terms the complexity of a patient’s condition and the resources used are not captured by the coding system, which ultimately affects a hospitals case-mix index (Cheng et al, 2009).
The need for accurate coded data from quality documentation goes way beyond the hospital setting and has many different purposes. These include benchmarking, compliance with national quality and safety standards, clinical research, health service planning and policies at local, national and international level (World Health Organisation, 2012).
The CDS role involves reviewing clinical documentation concurrently during the inpatient episode of care. The purpose of improving the quality of documentation is to not only ensure the correct DRG is allocated for coding purposes, it also offers a unique opportunity to improve patient safety and quality outcomes. The Commission broadened the scope of standard six ‘Communicating for Safety’ and acknowledged communication as critical throughout a patient’s care. It also stressed the relevance of effective communication across all of the standards.
Given this background, there is potential for a CDS with strong leadership, clinical and investigative skills to impact in the following areas:
- Improve clinical documentation through clinician engagement and education
- Analyse documentation in real time to ensure the correct principal and additional diagnoses have been documented and in a manner which can be translated into coded data
- Monitor whether clinical documentation is meeting the NSQHS standards
- Monitor and improve documentation for relevant safety and quality indicators, for example, hospital acquired complications and unplanned readmissions.
Whilst the current evidence is limited on the full benefits of CDI programs, what is clear is the relationship between poor documentation, negative patient outcomes and the quality of coded data. This lends support for initiatives which aim to improve documentation in the clinical record.
The CDS role has the potential to evolve and become pivotal in improving communication in hospital systems. Experienced motivated nurses have the background to review clinical records, the knowledge to discuss documentation issues with clinicians and most importantly they care and have knowledge about quality, safety and patient outcomes. The combination of which makes nurses ideal candidates to become clinical documentation improvement specialists.
Australian Commission on Safety and Quality in Health Care (2017), National Safety and Quality Health Service Standards. 2nd ed. ACSQHC, Sydney.
Brown, L.R., 2013, The secret life of a clinical documentation improvement specialist, Nursing. vol.43, no.2, pp 10–12.
Buttner, P., Comfort, A., Devrick, J., Endicott, M., Kohn, D., Lo, W., Ward, M., Wiedemann, L. & Zender, A. (2014), ‘Leading the Documentation Journey’: A Report from the AHIMA 2014 Clinical Documentation Improvement Summit. In: Clinical Documentation Improvement Summit. Washington, DC: AHIMA.
Cheng.P., Gilchrist.A., Robinson.K.M., & Paul.L (2009), The risk and consequences of clinical miscoding due to inadequate medical documentation: a case study of the impact on health services funding
World Health Organisation, (2012), Uses of Coded clinical Data. WHO Family of International Classifications Network [http://www.who.int/classifications/en/].