Successful Collaboration in Healthcare : A Guide for Physicians, Nurses and Clinical Documentation Specialists book cover
1st Edition

Successful Collaboration in Healthcare
A Guide for Physicians, Nurses and Clinical Documentation Specialists

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ISBN 9781439812921
Published January 27, 2010 by Productivity Press
136 Pages - 12 B/W Illustrations

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Book Description

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 –

  • Show how to build trust and communication and demonstrates specific opportunities where collaboration can make all the difference
  • Identify ways that quality of care and financial factors overlap and the advantages that can be garnered through an understanding of this
  • Explain how those in different roles view information through different types of knowledge and how an understanding of each perspective makes it easier to find the best source for important answers
  • Discuss the education and ever-increasing role of the clinical documentation specialist who is often involved in all facets of a patient’s progress, from intake and admission right up through discharge.

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.

Table of Contents

Chapter 1 Introduction
Chapter 2
Building Trust and Communication
Communication Styles
Aspects of Communication
Communication and Trust
Emotional Maturity
Communication Assessment
Code of Conduct
Communication Template
SBAR: Situation, Background, Assessment, and Recommendation
Knowledge Differences
Working Together
Nursing Roles and Collaboration
Other Opportunities to Collaborate
Chapter 3 Impacts: Quality and Financial
Length of Stay and Diagnosis-Related Groups
Hospital-Acquired Conditions
Present on Admission
Impacts of DRGs, POA, and HAC
Post-acute Transfer Policy
Outlier Payments
Public Reporting
Recovery Audit Contractors
Considerations for Preparing for RAC
Chapter 4 Clinical Documentation Specialist: Who Is Involved and What Is the Process?
CDS Role
CDS Process
CDS Worksheet
Unit-Based versus Physician-Based Model
Chart Review
Query Aspects
Query Criteria
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
CDS Support
Chapter 5 Clinical Documentation Specialist and Education
CDS Training
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
Applying Change
Chapter 6 Collaboration with Hospital Case Management
Case Management Legal and Quality Considerations
Case Management and Ethical Aspects
Importance of Clinical Knowledge and
Case Management
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
Scenario 1
Scenario 2
Scenario 3
Scenario 4
Chapter 8 Final Thoughts

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MSN, RN, CMSRN, Clinical Documentation Management Specialist FHN Memorial Hospital


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