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

Successful Collaboration in Healthcare

A Guide for Physicians, Nurses and Clinical Documentation Specialists, 1st Edition

By Colleen M. Stukenberg

Productivity Press

136 pages | 12 B/W Illus.

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pub: 2010-01-27
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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.


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

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



About the Author

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

Subject Categories

BISAC Subject Codes/Headings:
BUSINESS & ECONOMICS / Quality Control
BUSINESS & ECONOMICS / Industries / Service Industries
MEDICAL / Administration