CDI peer review audit tool

donna.kentdonna.kent
in CDI Talk Archive
Does anyone have a CDI peer review audit tool that is more robust than just focusing on queries? While the query aspect is important, there is more to the job than that. If I don't have to reinvent the wheel I'd appreciate any help you all can share.

Thanks,
Donna

Comments

  • fishdl@shands.ufl.edufishdl@shands.ufl.edu
    edited May 2016
    Contact me directly and I'll send what we use for annual self-evaluation.
    Another Donna :-)

    fishdl@shands.ufl.edu
  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited May 2016
    This is something that I've been developing. Played with it a little today before sending. I often have tools that are in a somewhat permanent 'draft' status -- I tweak as I learn from using, and it was time to tweak it (again).

    By having specific questions, with essentially Y/N/NA as only answers(all questions are intended to be worded such that the 'good' answer is Yes), it is designed to load the review data into a database and then calculate percentages for an entire team as well as for the individual CDS. I like percentages, graphs, trends over time, comparison, etc. Also helps to set standard levels of performance.

    Several of the questions do not include all of the reasonable options (such as the reasons for a query -- question #9) however in those cases, existing P&P as well as the AHIMA briefs should be considered incorporated in full detail when auditing the record.

    For questions 3 & 15, the sub-set questions are N/A unless the initial question is No, in which case are able to drill down more specifically to what are the issues.

    Though not specifically identified as references on the tool itself, consider both of the AHIMA briefs as cited references, as well as my / your organization P&P -- and we all have those, right? :)

    If you have a large enough team and opt to do peer reviews, then having each record reviewed independently (and blindly) by 2 CDS's allows establishing inter-rater reliability. If there is significant disagreement on any one case, then should be referred to manager for final review.

    If one is a single person shop, then either consider if there is a strong person in Coding, compliance, etc. who could do an audit, or at the very least, do self audits.

    Audit's can be performed in a variety of ways, consider: peer to peer, leadership, compliance, coding... depends on resources, size, expertise.

    PLEASE, make sure that you edit this to reflect your own needs and most importantly, your P&P.

    There is a white paper, as well as a ppt on Auditing available (given at a NC ACDIS meeting)
    The PPT in Forms & Tools: Butler Auditing Tool http://www.hcpro.com/content/279047.ppt
    A link to the white paper: http://www.hcpro.com/content/268350.pdf ; http://blogs.hcpro.com/acdis/2011/07/white-paper-audit-your-cdi-program-to-avoid-pitfalls/

    LOVE to hear feedback & suggestions!
    Don
  • wchenneywchenney
    edited May 2016
    This is great--thanks for sharing

    Wendy R. Chenney RN BSN
    Manager Clinical Documentation
    Parma Community General Hospital
    Office: (440) 743-4533
    Fax: (440) 743-4552
    Pager: (440) 675-5929
  • robert.hodges2robert.hodges2
    Very nice Paul. Thanks for sharing. Fran Jurcak has a similar tool that I have seen that has a score attached to it for a quantified review.

    Oh yea, and to any Veteran's out there. Happy Veteran's Day and thank you for your service.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Former Major, U.S. Army Nurse Corps
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
  • robert.hodges2robert.hodges2
    Oops, I meant Don. I was thinking of another email. Sorry for not giving you credit for your work here Don.

    Robert
  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited May 2016
    If you felt that was up to Paul's standards....I take that as a real COMPLIMENT!!

    Don
  • donna.kentdonna.kent
    You guys are all amazing. I always feel so supported. Thanks.
    Donna
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Thanks, Don....

    Robert - A word of thanks to all of our Vets and to the VA. I am an ARMY vet and I obtained by RHIA B.S. via my VA educational benefits...I proudly served in the U.S. Army in a Medical Unit. The experience was invaluable. I would never have funded my success w/o having served.


    Paul

    Paul Evans, RHIA, CCS, CCS-P, CCDS
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    Great tool, Don.

    Paul Evans

    Paul Evans, RHIA, CCS, CCS-P, CCDS
  • Unknown
    edited May 2016
    Thank-you Paul.
    We are indebted to our veterans for the freedoms we still enjoy.

    To all who served, Thank-you.


    Charlene
  • gwojogwojo
    edited May 2016
    Paul,

    Thank you to you and your fellow vets. You are very much appreciated and I don't believe you all receive the credit you deserve.


    Francisca Wojciechowski, BS, RHIA, RHIT, CCDS

    AHIMA-Approved ICD-10-CM/PCS Trainer
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