Problem: After reading about CDI in the overview, consider the following scenario:
You are a clinical documentation improvement specialist at an acute care facility with approximately 75 full-time physicians. You have been given the responsibility of developing the CDI process. You and your staff of five nurses are responsible for reviewing the documentation found in the charts while patients are still in-house. You find that the query process for the providers has never been fully understood by the providers. Some of the providers feel their medical expertise is being questioned.
What steps could you take to help your staff and the medical staff overcomes any misunderstanding that may be preventing the clinical documentation improvement process from being effective in this facility?
Consider the purpose of the Medical Staff Bylaws, and whether documentation is covered in the Bylaws (found in the module readings).