daily review process

rmhosler1rmhosler1
edited April 2016 in CDI Talk Archive
Hi everyone:

Was wondering if anyone had a policy regarding CDS reviews/re-reviews
they would be willing to share?


Thanks in advance!!



Mary A Hosler MSN, RN
Clinical Documentation Specialist
Alumnus CCRN
McLaren Bay Region
1900 Columbus Ave.
Bay City, Michigan 48708
(989) 891-8072
mary.hosler@mclaren.org

"The difference between the right word and the almost right word is the
difference between lightning and the lightning bug." Samuel "Mark Twain"
Clemens








Comments

  • angelisa.romanelloangelisa.romanello
    edited April 2016
    Mary,
    Here is a piece of our policy.

    FREQUENCY and VOLUME of Medical Record Review:
    Records will be reviewed no sooner than twenty-four hours from the time of admission. The CDIS should maintain a review rate of 85% of those records identified under the scope of the program. Review frequency and volume may be impacted by staffing and patient population fluctuations. Record reviews will be prioritized as follows:
    1- Admissions
    2- Open cases with queries awaiting physician response
    3- Open cases with extended lengths of stay
    4- Retrospectively, records awaiting final DRG assignment by HIM/HSC will be reviewed by the CDI staff no less frequently than weekly.
    Re-Reviews are to be completed every three days depending on the above and staffing metrics.

    Lisa Romanello, RN,BSN,FNS,CCDS
    Manager, Clinical Documentation Improvement
    Quality and Compliance
    CJW Medical Center
    804-228-6527
    AHIMA Approved ICD-10 CM/PCS Trainer
    Co-Chair of CJW Nursing Informatics
    Angelisa.Romanello@HCAHealthcare.com





  • paxnerospaxneros
  • angelisa.romanelloangelisa.romanello
    edited April 2016
    No we do not. We are required to capture those on Monday morning

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Wednesday, June 18, 2014 12:16 PM
    To: Romanello Angelisa
    Subject: Re: [cdi_talk] daily review process

    Do you work weekends to capture the weekend admissions w/in 24 Hours

    Thanks,
    Norma T. Brunson,RHIA,CDIP,CCS,CCDS


  • paxnerospaxneros
    edited April 2016
    Mary,

    For admissions our policy states:

    "The CDS is to review each admission within 48 hour

    Sent from my Verizon Wireless 4G LTE DROID

  • paxnerospaxneros
    Mary,

    Our most current policy states for admissions & concurrent (follow-up)reviews:

    "The Clinical Documentation Specialist (CDS) is to review each admission(concurrent review) within 48 hours when possible (exceptions are discharges, daily workload, weekends, employee absence, and external forces)."

    We do not work weekends, therefore on Monday we are 3 days behind (Friday/Saturday/Sunday). We have 3 Staff members currently who are able to review and some Mondays we have 20- 25 new admissions to review. Rather than paint ourselves into a corner we allow 48 hours to review new admissions.

    Sometimes, we simply do not have any information in the record for up to 48 hours past admission.

    We also have patients who come in on Friday and are discharged on Monday. Those patients may - or may not - be reviewed. It depends on whether they make our list or not before discharge. When we have employees on vacation, we are limited as to how many patients we can see because we may have to double or triple-up.

    External forces are any other occasions which impact our ability to review a patient - in Florida it could be a Hurricane - or - this Winter - we had an "Ice Day". Also, we are considered "non-clinical" & often Non-Clinical Depts. are hit with Mandatory Paid Time Off.

    To say the least, we mostly get our work done in the 24 hour time-frame, but we allow up to 48 hours for completion.

    Thanks,

    Norma T. Brunson, RHIA, CDIP, CCS, CCDS
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