NCHIMA | Turbo CDI-Advancing Knowledge In Physician Documentation Integrity-Investing in Oneself Workshop

A competent Clinical Documentation Integrity Specialist requires fundamental knowledge and core competencies necessary to review a medical record for purposes of identifying opportunities for clarification of diagnoses with clinical specificity, resolution of documentation discrepancies, clarification of Present on Admission Indicators/Hospital Acquired Conditions/PSIs, and accurate reporting other quality and safety measures. A highly performing Clinical Documentation Integrity Specialists operating at the top of his/her game possesses the necessary skill sets, core competencies, knowledgebase, and confidence to conduct a “holistic” review of the medical record, identify, and even more importantly address true documentation insufficiencies The Turbo CDI Workshop is intended for those CDI professions who have the drive to continually improve their knowledge of best practice standards and principles of documentation, recognize that Physician Documentation improvement Programs must be geared towards helping physicians become more proficient in documentation and communication of patient care, and desire to partner with physicians as guides and mentors for better documentation in the spirit and name of quality patient care. The workshop includes six separate presentations, each one designed and intended to equip the CDI specialists with the knowledge and skill sets to incorporate other key elements to the chart review process including elements of medical necessity, assessment of complete and accurate documentation as defined by Medicare, evaluation of progress notes for continued hospitalization, and ability of Discharge Summaries to meet the Joint Commission requirements and guidelines for Discharge Summaries issued by the Society for Hospital Medicine. Real case studies will be used as part of the presentations along with interactive learning techniques including break out sessions with attendees. All attendees will be provided resources to take back to their facility to be put into practical use, helping integrate a holistic approach to chart review. Pre-workshop homework assignments will be provided to all attendees with instructions to arrive with completed homework assignments. There will be ample time for questions and answers during and after each presentation.

Learning Objectives:

1. Defining clinical documentation and the medical record as a communication tool- what are the minimum elements
2. Reviewing the medical record, recognizing, and addressing true documentation insufficiencies with the physician in a proactive manner
3. Heightening and strengthening the role of CDI in helping physician establish and accurately report medical necessity for hospital level of care
4. Using and applying Medicare’s definition of “Complete and Accurate” Documentation to transform CDI from Reactive to Proactive, helping physicians achieve proactive preemptive denials avoidance documentation
5. Establishing a strong collaborative synergistic working relationship with Case Management, Utilization Review, Physician Advisor(s), and Coding to achieve sustainable improvement in physician documentation with a byproduct of optimal net patient revenue
6. Maintaining relevancy and Up-to-Date knowledge in best practice standards and principles of documentation through self-learning