Clinical Documentation Improvement Program
The Clinical Documentation Improvement program aims at the enhancement of the effectiveness of the paperwork and information processing within the health care organization. In such a situation, health information management plays a particularly important part because it helps to manage information effectively and minimize the risk of information breaches as well as enhance the performance of health care professionals due to better information processing. The proposed CDI program aims at the establishment of the inhouse agency that would conduct regular monitoring and auditing of the performance and information processing of health care organization and facilitate the information sharing within the organization as well as between health care professionals and their clients. In such a way, the proposed CDI program would optimize the information processing and secure sensitive information concerning the health of patients.Clinical Documentation Improvement Program
In house or outside agency
In fact, the proposed CDI program focuses on the creation of the inhouse agency that will be responsible for the improvement of the documentation processing and managmet within the health care organization (Scott, 2001). In this regard, there are two options: either to create the inhouse or outside agency. Both options have their pros and cons. The proposed CDI program focuses on the creation of the inhouse agency because this is the better option because the agency will be able to monitor CDI program and the performance of the health care organization in regard to the information processing directly since the agency will be located in the hospital and, thus, the agency will be able to supervise, monitor and report on any issues that may arise in the course of the implementation of the CDI program. The major drawback of the inhouse agency is the necessity of employing the full-time staff that will work along with health care professionals that will increase the costs of the program and may lead to inconveniences for health care professionals caused by monitoring and other activities conducted by employees of the agency.
Alternatively, the outside agency can be created to implement and manage the proposed CDI program. In fact, the outside agency will allow saving costs because such agency may employ part-time employees and conduct monitoring and auditing once a month or week, for instance, and report on the implementation and functioning of the program to the committee. However, such alternative has a substantial drawback since the outside agency can fail to monitor and control the implementation and functioning of the CDI program effectively. Occasional monitoring and auditing may fail to uncover possible problems which may be identified only through daily observation, monitoring and control of the implementation and functioning of the CDI program. This is why the inside agency was chosen as the best option for the proposed CDI program.Clinical Documentation Improvement Program
Oversight, monitoring and reporting
The implementation of the CDI program will need oversight, monitoring and reporting. In such a way, the CDI program will be under the control of the committee and help the organization to complete the implementation of the program successfully. The oversight over the program should be conducted by the manager responsible for the development and implementation of the program. The manager will appoint assistants or employees, who can monitor the implementation of the program and its functioning within the target health care organization. Employees will conduct monitoring through the regular observation and control over the implementation of the CDI program. They will audit the functioning of the CDI program and how the documentation is processed and managed within the organization compared to the proposed processing and management of the clinical documentation in terms of the CDI (Miller, 2000). In case of the identification of any challenges or problems, employees will report to the manager of the CDI program immediately. At the same time, they should also report weekly on the implementation and management of the CDI program, if there are no problems identified. The manager will analyze the information received from reports of employees and report to the committee once a month on the implementation and functioning of the program.Clinical Documentation Improvement Program
Documentation content
The documentation content should focus on the collection and securing all the information required by health care professionals to perform their duties and functions properly. All the documentation should be secured, including the history of each patient, their private information, such as name, age, address, and other relevant information. At the same time, the CDI program can admit the omission of nursing notes which may overload the program and the staff with excessive information and documentation which though does not play a significant part in the overall documentation turnover within the health care organization and has no effect on clients and health care professionals working within the organization.
Physician queries
However, the implementation of the program may raise physician queries since they may grow concerned about the non-interference of employees involved in the CDI program into their performance (Solovy, 1995). To tackle this program, the CDI program will involve the formation of the committee involving physicians, representatives of the board of the health care organizations, and the manager of the CDI program. The committee will supervise the program on the ground of reports of the program manager and reports filed by any of the committee member concerning the implementation and functioning of the program.
Medical staff training
The medical staff will need training to be able to use the full potential of the CDI program. The training will enroll all health care professionals affected by the program. The training will be conducted by employees involved in the CDI program, who will help health care professionals to learn all the information they need about the program.Clinical Documentation Improvement Program
Training for coders
The coders will also need training. This training will be conducted by the CDI program manager, who will explain the essence of the program, functions of each employee, goals of the program and expected outcomes as well as the system of reporting and monitoring.
Staff qualification and credentialing
The staff involved in the CDI program should be qualified to manage the program. They should have the bachelor degree at the least, while the manager of the program should have the master degree.
Conclusion
Thus, the implementation and management of the CDI program will involve the elaboration of the plan of the implementation of the program, oversight, monitoring and control. The latter will involve the system of reporting from employees of the program to the program manager and from the manager to the program committee. In such a way, the CDI program may be implemented successfully and improve the documentation processing within the health care organization.Clinical Documentation Improvement Program