Legacy increases documentation support

Legacy Health has increased its Clinical Documentation Improvement staff by 188% in order to better support the transition to ICD-10 documentation terms and standards.

What is a Clinical Documentation Improvement specialist?

Clinical Documentation Improvement (CDI) specialists review patient medical records and assess whether all conditions and treatments are documented in specific diagnostic terms. The goal is to paint an accurate picture of the severity of a patient’s illnesses and risk of mortality.

CDIS

 

The CDI team:
(Back row from left): Linda Calvert, Maryl McCarthy, Ceci Jones, Nadja Paea, Debra Silva, Jeanette Judd, Cindy Jackson, Evelyn Smith, Kathryn Eastwood, Linda Haynes 
(Front row from left ): Eileen Guenther, Molly Siebert, Natesa Larson, Karen Maritano, Marjorie Aranda, Gloria Blanchard

   

 

How do CDI specialists help providers?

  • They respond real-time to provider inquiries
  • They review the EHR while the patient is in-house to assure documentation reflects:
    • quality of patient care
    • continuity of care among providers
    • diagnosis and procedure specificity
    • clarification of conflicting or missing information
  • They alert providers when documentation needs clarification
  • They attend provider meetings to give feedback and education on changes in documentation requirements
  • They train new physicians/residents and other providers about documentation needs

 Have a question? Contact Linda Haynes, CDI manager.