A recent Q&A around how to review a chart by a CDI reminded me that so much has changed since 2005 when I began my adventure into the world of Clinical Documentation Improvement (CDI). The move from reimbursement first and foremost to accurate documentation has been such a turning point.
The introduction of the Electronic Medical Record (EMR) has been both a positive and a negative. I remember when labs and x-rays were the first pieces of the medical record to be electronic. They were the easiest to review at any time since we did not have to wait on the paper chart from the provider or a nurse using it.
As the electronic record has evolved and the majority of the record is available to all in real time, the way that I do a CDI review has evolved as well. I try to remember that my job is to accurately reflect the patient’s illness and encounter when I do my reviews. I want to make sure that I understand the story from the providers' stand point.
- I start at the beginning and review the ED notes when that is the point of entry and the clinic notes when that is the point of entry.
- My next document is the H&P, followed by consults and daily progress notes in chronological order.
- With the assistance of the encoder and the application of ICD-9 codes, I can then look to see what the DRG is and the SOI/ROM to help me to decide if a more extensive review of Labs, Nurses' Notes, Dietitian Notes, and other ancillary service providers is warranted.
I have learned that not every chart needs to be reviewed in the same manner and with time, many providers are very good documenters. The good education provided by CDI over time will pay off in that not every chart will require looking outside the medical provider’s (MD, PA, NP) notes.