136 pages | 12 B/W Illus.
This critically acclaimed work makes the case for collaboration and shows that it can be greatly enhanced with conscious understanding and systematic effort. As a healthcare specialist who has worn many hats from direct care giver to case manager to documentation specialist, Colleen Stukenberg is able to –
As the author points out, good healthcare is dependent on the right person performing the right role, which promotes excellent collaboration. And when people are allowed to function in their proper roles, job satisfaction increases, which in itself leads to better attitudes, which then leads to even deeper levels of collaboration and with it, the successful promotion of safe, quality care.
With the rising importance of health care information, this book provides a broad but detailed overview of the role of the clinical documentation specialist (CDS). … The author, who has more than 20 years of nursing experience, portrays the role of nursing with accuracy and acumen. Her publication is unique, as evidenced by my literature search, which uncovered only two articles on the topic of the CDS. This book provides not only a comprehensive description of the CDS role, but also an excellent overview of the financial aspects of health care, especially coding and accurate diagnosis-related group (DRG) classification. … Overall, this book is an excellent resource for all clinicians who relate to the issues in health care that affect safe and quality patient care, the key word being collaboration.
—Donna L. Baker, MS, APRN, ACNS-BC, CNOR, Medical Science Liaison Baxter Healthcare, in AORN Journal, Vol. 92, No. 6, December 2010
Colleen Stukenberg writes from the perspective of one who has been there and done that. She is a skilled teacher who shares lessons she has learned in the trenches.
—Beth Gale, RN, BSN
Colleen has successfully navigated the clinical and front-end-revenue cycle job market over the last 20 years. Her acute care nursing, case management, and long-term care experience has built a well rounded and solid foundation for our Clinical Documentation program. Her vast knowledge and know-how has actualized one of the more successful documentation programs in the industry with the financial gains in a rural hospital rivaling major urban medical centers. Colleen is definitely an authority on Clinical Documentation programs and has much to share with her peers.
—Tamar Gorenyuk, MBA, RHIA, Director, HIM & Resource Management, Freeport Health Network
Colleen is a recognized expert in the field of Clinical Documentation Improvement (CDI). Anyone interested in implementing a successful Clinical Documentation Improvement Program should read this book before starting the process. Never before has this valuable information been presented in one, all-encompassing reference. The material covered in this book will help executives make informed choices about whether or not to hire a consulting firm and if so, which firm will best meet their needs. Colleen's perspective and experience implementing a CDI program provides the reader with time-tested tools of the trade and advice that will help guide new CDI Programs to excellence while avoiding the common challenges faced by faltering CDI Programs.
— Lynne Spryszak, RN, CCDS, CPC-A, Manager, Precyse Solutions, LLC
Chapter 1 Introduction
Chapter 2 Building Trust and Communication
Aspects of Communication
Communication and Trust
Code of Conduct
SBAR: Situation, Background, Assessment, and Recommendation
Nursing Roles and Collaboration
Other Opportunities to Collaborate
Chapter 3 Impacts: Quality and Financial
Length of Stay and Diagnosis-Related Groups
Present on Admission
Impacts of DRGs, POA, and HAC
Post-acute Transfer Policy
Recovery Audit Contractors
Considerations for Preparing for RAC
Chapter 4 Clinical Documentation Specialist: Who Is Involved and What Is the Process?
Unit-Based versus Physician-Based Model
Systematic Review Method
Physician Response Concerns
The Working DRG Assignment and Impacts
An Internal Audit
Completing the Loop
Data Collection and Considerations
CDS Role Allocations and Job Description
Chapter 5 Clinical Documentation Specialist and Education
Clinical Knowledge and Experience
Coding and DRG Terms
The Query Process
CDS Continued Education
CDS and Nursing Education
CDS and Physician Education
Keeping Current and Understanding Change
Chapter 6 Collaboration with Hospital Case Management
Case Management Legal and Quality Considerations
Case Management and Ethical Aspects
Importance of Clinical Knowledge and
Terms for the Case Manager
Case Management and the Admission Process
Case Management and Physician Collaboration
Case Management and Accurate Documentation
The Discharge Plan
Discharge Planning Checklist
Multidisciplinary Team and Discharge Planning
Case Management and Post-discharge Follow-Up
Case Management and Data Collection
Chapter 7 Putting It All Together
Chapter 8 Final Thoughts