Clinical documentation

Respond to at least two of your colleagues’ posts by offering suggestions/strategies for working with this database from your own experience, or offering ideas for using alternative resources.

at least 2 references in each peer responses! 

Clinical documentation improvement seems to be a very gray area of nursing and in the medical field, in general. Most times, nurses working in this field find ourselves educating physicians and hospital administration about the importance of our program and how it impacts quality outcomes for the hospital. Most hospital administrations and physicians like to think of our department as dealing with hospital reimbursement. While part of this may have been true when the programs were created with most CDI program falling under a revenue cycle department, programs are now quality driven. Clinical documentation affects patient outcomes by showing the severity of illness and case mix index of a specific DRG while capturing all of the comorbid conditions that also affect a stay, such as diabetes with hyperglycemia. Finding peer reviewed articles, like the ones below, provide evidence of how a CDI program helps to improve everything from length of stays and better outcomes for patients and families.

I was honestly very surprised to find so many articles in the ScienceDirect area of the Walden Library. I have been looking for articles such as these to help support our program in Tampa with our physicians. Ongoing education and support is something that I am always striving to bring to our physicians. It is very difficult to show the worth of your program to physicians and administration without discussing dollars and cents. I would definitely love to share this information with my colleagues, both nurses and physicians. Sometimes, physicians need additional resources to help them understand. Nurses working in this field can always use more resources to help better assist them in explaining and using evidence to explain and validate why our program is so important.

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