Sitting side by side with a Clinical Documentation Specialist last week reviewing some records, I realized how much I hate reviewing a record and finding no reason to query. For me, the joy in CDI is finding the unspecified, the unwritten or even the undiagnosed. To me, this is how I’m able to utilize my knowledge and clinical expertise to support improving the quality of patient care. How often have you spent fifteen to twenty minutes searching through a record only to determine that there is not a query opportunity?
You end up reviewing hundreds of data points in the record yet find no clinical indicators to support a compliant query. Maybe the physician was having a slow day and remembered to include all the diagnoses being monitored and treated and even specified each diagnosis thoroughly. Or maybe the documentation is so vague and not enough results are back that a compliant query is not needed. Either way, you’ve just wasted 15-20 minutes of time that could be better spent in a record with documentation opportunities. Question is, how can you quickly and easily find the records with documentation opportunities?
Software technology is now able to review medical record information and create a prioritized worklist, pointing a CDS to the records with greater opportunity for documentation accuracy. Using big data, Iodine Software’s Smartlist identifies trends and patterns that can be utilized to predict when medical conditions are being monitored and treated during a patient’s inpatient admission. Add the ability to read the documentation and identify missing specificity and clarity, and now you have a prioritized list of patient records that require a CDS’s review for a possible documentation improvement opportunity.
Increasing efficiency and allowing CDS’s to focus attention on medical records with the greatest opportunity of documentation improvement are the hallmarks of Iodine’s Smartlist and the key reasons why I joined Iodine’s innovative team. I love creating efficiency for the CDS daily workflow and our clients are seeing this efficiency translate into positive results.