Record Review in the Unites

edited March 2016 in General
Hi Everyone,
Those working in CDI with a complete electronic record, do you review records in the unites. If not, how often do you go to the floor (provide Face to Face time) in a week? Just would like to get an idea of the impact EHRs have had on CDI chart reviews.


Sincerely,


Stacey Butler, RHIA, CDIP, CCS, CCS-P
Coding Manager, Hospital Coding & CDI
Health Information Management Department
Arkansas Children's Hospital
1 Children's Way | Slot 109 | Little Rock, AR 72202
501.364.1127 direct | 501.364.1152 office | 501.364.3968 fax
butlers@archildrens.org

Comments

  • We have a completely electronic EHR, working from home 1 day a week and my team works up on the floor (to increase visibility) 4-6 hours a week. They also do 'face-to-face' with the physicians when needed.

    Patty



    Patricia Matson Vitasinski RN CCDS

    Supervisor of Clinical Documentation

    Henry Ford West Bloomfield Hospital

    248 325-0204 office

    248 875-4969 cell

    email- pvitasi2@hfhs.org



    Please note new cell phone contact information



    ________________________________
    From: CDI Talk
    Sent: Tuesday, February 23, 2016 10:29 AM
    To: Vitasinski, Patricia
    Subject: [cdi_talk] Record Review in the Unites

    Hi Everyone,
    Those working in CDI with a complete electronic record, do you review records in the unites. If not, how often do you go to the floor (provide Face to Face time) in a week? Just would like to get an idea of the impact EHRs have had on CDI chart reviews.


    Sincerely,


    Stacey Butler, RHIA, CDIP, CCS, CCS-P
    Coding Manager, Hospital Coding & CDI
    Health Information Management Department
    Arkansas Children's Hospital
    1 Children's Way | Slot 109 | Little Rock, AR 72202
    501.364.1127 direct | 501.364.1152 office | 501.364.3968 fax
    butlers@archildrens.org



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    Copyright 2013
    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923

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  • Does any other hospital out there also have work from home hours?

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, February 23, 2016 10:44 AM
    To: Debra L. Mullen
    Subject: Re:[cdi_talk] Record Review in the Unites


    We have a completely electronic EHR, working from home 1 day a week and my team works up on the floor (to increase visibility) 4-6 hours a week. They also do 'face-to-face' with the physicians when needed.

    Patty



    Patricia Matson Vitasinski RN CCDS

    Supervisor of Clinical Documentation

    Henry Ford West Bloomfield Hospital

    248 325-0204 office

    248 875-4969 cell

    email- pvitasi2@hfhs.org



    Please note new cell phone contact information



    ________________________________
    From: CDI Talk
    Sent: Tuesday, February 23, 2016 10:29 AM
    To: Vitasinski, Patricia
    Subject: [cdi_talk] Record Review in the Unites

    Hi Everyone,
    Those working in CDI with a complete electronic record, do you review records in the unites. If not, how often do you go to the floor (provide Face to Face time) in a week? Just would like to get an idea of the impact EHRs have had on CDI chart reviews.


    Sincerely,


    Stacey Butler, RHIA, CDIP, CCS, CCS-P
    Coding Manager, Hospital Coding & CDI
    Health Information Management Department
    Arkansas Children's Hospital
    1 Children's Way | Slot 109 | Little Rock, AR 72202
    501.364.1127 direct | 501.364.1152 office | 501.364.3968 fax
    butlers@archildrens.org



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    Copyright 2013

    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923

    ________________________________

    CONFIDENTIALITY NOTICE: This email contains information from the sender that may be CONFIDENTIAL, LEGALLY PRIVILEGED, PROPRIETARY or otherwise protected from disclosure. This email is intended for use only by the person or entity to whom it is addressed. If you are not the intended recipient, any use, disclosure, copying, distribution, printing, or any action taken in reliance on the contents of this email, is strictly prohibited. If you received this email in error, please contact the sending party by reply email, delete the email from your computer system and shred any paper copies.

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  • We do not have work at home hours at this time for adult/peds CDI.

    Claudine Hutchinson RN (CDI)

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, February 23, 2016 09:46 AM
    To: Hutchinson, Claudine
    Subject: RE:[cdi_talk] Record Review in the Unites

    Does any other hospital out there also have work from home hours?

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, February 23, 2016 10:44 AM
    To: Debra L. Mullen
    Subject: Re:[cdi_talk] Record Review in the Unites


    We have a completely electronic EHR, working from home 1 day a week and my team works up on the floor (to increase visibility) 4-6 hours a week. They also do 'face-to-face' with the physicians when needed.

    Patty



    Patricia Matson Vitasinski RN CCDS

    Supervisor of Clinical Documentation

    Henry Ford West Bloomfield Hospital

    248 325-0204 office

    248 875-4969 cell

    email- pvitasi2@hfhs.org



    Please note new cell phone contact information



    ________________________________
    From: CDI Talk
    Sent: Tuesday, February 23, 2016 10:29 AM
    To: Vitasinski, Patricia
    Subject: [cdi_talk] Record Review in the Unites

    Hi Everyone,
    Those working in CDI with a complete electronic record, do you review records in the unites. If not, how often do you go to the floor (provide Face to Face time) in a week? Just would like to get an idea of the impact EHRs have had on CDI chart reviews.


    Sincerely,


    Stacey Butler, RHIA, CDIP, CCS, CCS-P
    Coding Manager, Hospital Coding & CDI
    Health Information Management Department
    Arkansas Children's Hospital
    1 Children's Way | Slot 109 | Little Rock, AR 72202
    501.364.1127 direct | 501.364.1152 office | 501.364.3968 fax
    butlers@archildrens.org



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    If you would like to be removed from CDI Talk, please send a blank email to

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    Copyright 2013

    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923

    ________________________________

    CONFIDENTIALITY NOTICE: This email contains information from the sender that may be CONFIDENTIAL, LEGALLY PRIVILEGED, PROPRIETARY or otherwise protected from disclosure. This email is intended for use only by the person or entity to whom it is addressed. If you are not the intended recipient, any use, disclosure, copying, distribution, printing, or any action taken in reliance on the contents of this email, is strictly prohibited. If you received this email in error, please contact the sending party by reply email, delete the email from your computer system and shred any paper copies.

    Note to Patients: There are a number of risks you should consider before using e-mail to communicate with us. See our Privacy & Security page on www.henryford.com for more detailed information as well as information concerning MyChart, our new patient portal. If you do not believe that our policy gives you the privacy and security protection you need, do not send e-mail or Internet communications to us.



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    Copyright 2013

    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
    CONFIDENTIALITY NOTICE: This email message, including any attachments, is for the use of the intended recipient(s) only and may contain information that is privileged, confidential, and prohibited from unauthorized disclosure under applicable law. If you are not the intended recipient of this message, any dissemination, distribution, or copying of this message is strictly prohibited. If you received this message in error, please notify the sender by reply email and destroy all copies of the original message and attachments.



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    Saint Francis Health System intends this email only for the use of the person to whom it is addressed and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If you have received this email in error, you are hereby notified that we do not consent to any reading, dissemination, distribution, or copying of this email and request you notify the sender immediately and destroy this transmission. Violators may be prosecuted under Federal law.
  • We are all electronic-which means almost all of the time we work from the desk. I know from having worked in this position for 6 years and watching it grow from a paper process-where we saw 4 patients a day-and hunting down providers and charts to review, that I prefer our process now. We usually review 25-30 charts (including re-reviews) a day. Our census review has increased exponentially-as has the need for CDI. We are now 6 strong and review all deaths, all Medicare, do the restraints process as well as code status. We still "round" occasionally on the floors-but found when we did, that providers never had questions for us-or were too busy to speak with us, and said they would "call" if they needed us. :) And they do-

    To maintain being visible-which was a concern, we make posters to hang about trending topics, we attend and educate at provider huddles (voluntary for them to attend), go to provider meetings, and do 1:1 education for all incoming providers. We also attend and do a slide presentation annually at the Family Medical Residency Clinic once they have gotten their feet wet. We tell the providers we will come to the floor (and often do) to explain a query, help sign a query, or for any other issues they need! Normally we run to help a Locums sign a query. Our regular staff providers recognize us and we maintain our communication with them constantly. We send both good examples of documentation and documentation that "need improving" to the provider liaison and that helps keep us on their minds, as she posts them on a board in the Physician lounge!

    It is difficult to maintain importance and being visible with an all EMR but we try and think of ways to maintain communication and visbility!

    Juli
    Juli Bovard RN CCDS
    Certified Clinical Documentation Specialist
    Clinical Effectiveness/Clinical Quality
    Rapid City Regional Hospital
    755-8426 (work)
    786-2677 (cell)
    "No Limit to Better......"
    [CCDS_pin_1inch]



    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, February 23, 2016 8:29 AM
    To: Bovard, Juli
    Subject: [cdi_talk] Record Review in the Unites

    Hi Everyone,

    Those working in CDI with a complete electronic record, do you review records in the unites. If not, how often do you go to the floor (provide Face to Face time) in a week? Just would like to get an idea of the impact EHRs have had on CDI chart reviews.


    Sincerely,


    Stacey Butler, RHIA, CDIP, CCS, CCS-P
    Coding Manager, Hospital Coding & CDI
    Health Information Management Department
    Arkansas Children's Hospital
    1 Children's Way | Slot 109 | Little Rock, AR 72202
    501.364.1127 direct | 501.364.1152 office | 501.364.3968 fax
    butlers@archildrens.org





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    Copyright 2013

    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923

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    Regional Health is an integrated health care system with the purpose of helping patients and communities live well.

    Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments.
  • We are completely electronic now as well.
    We no longer go to the floors to review charts.
    We are able to work from home two days a week and are onsite three days a week.
    We have biweekly (every other week) meetings with a representative from each of our Hospitalists Groups.
    If we notice documentation trends that need addressed or Queries that aren't being answered we can bring them up then.
    The ability to work from home a few days a week is great!
    I think face to face time with physicians is important but I also think that can be accomplished if you maximize your onsite days.
    I'm hoping that eventually we may be able to work from home more often, but there is no plan for that at this time....
    GG

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, February 23, 2016 10:46 AM
    To: Goodman, Greta
    Subject: RE:[cdi_talk] Record Review in the Unites

    Does any other hospital out there also have work from home hours?

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, February 23, 2016 10:44 AM
    To: Debra L. Mullen
    Subject: Re:[cdi_talk] Record Review in the Unites


    We have a completely electronic EHR, working from home 1 day a week and my team works up on the floor (to increase visibility) 4-6 hours a week. They also do 'face-to-face' with the physicians when needed.

    Patty



    Patricia Matson Vitasinski RN CCDS

    Supervisor of Clinical Documentation

    Henry Ford West Bloomfield Hospital

    248 325-0204 office

    248 875-4969 cell

    email- pvitasi2@hfhs.org



    Please note new cell phone contact information



    ________________________________
    From: CDI Talk
    Sent: Tuesday, February 23, 2016 10:29 AM
    To: Vitasinski, Patricia
    Subject: [cdi_talk] Record Review in the Unites

    Hi Everyone,
    Those working in CDI with a complete electronic record, do you review records in the unites. If not, how often do you go to the floor (provide Face to Face time) in a week? Just would like to get an idea of the impact EHRs have had on CDI chart reviews.


    Sincerely,


    Stacey Butler, RHIA, CDIP, CCS, CCS-P
    Coding Manager, Hospital Coding & CDI
    Health Information Management Department
    Arkansas Children's Hospital
    1 Children's Way | Slot 109 | Little Rock, AR 72202
    501.364.1127 direct | 501.364.1152 office | 501.364.3968 fax
    butlers@archildrens.org



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    Copyright 2013

    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923

    ________________________________

    CONFIDENTIALITY NOTICE: This email contains information from the sender that may be CONFIDENTIAL, LEGALLY PRIVILEGED, PROPRIETARY or otherwise protected from disclosure. This email is intended for use only by the person or entity to whom it is addressed. If you are not the intended recipient, any use, disclosure, copying, distribution, printing, or any action taken in reliance on the contents of this email, is strictly prohibited. If you received this email in error, please contact the sending party by reply email, delete the email from your computer system and shred any paper copies.

    Note to Patients: There are a number of risks you should consider before using e-mail to communicate with us. See our Privacy & Security page on www.henryford.com for more detailed information as well as information concerning MyChart, our new patient portal. If you do not believe that our policy gives you the privacy and security protection you need, do not send e-mail or Internet communications to us.



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    CONFIDENTIALITY NOTICE: This email message, including any attachments, is for the use of the intended recipient(s) only and may contain information that is privileged, confidential, and prohibited from unauthorized disclosure under applicable law. If you are not the intended recipient of this message, any dissemination, distribution, or copying of this message is strictly prohibited. If you received this message in error, please notify the sender by reply email and destroy all copies of the original message and attachments.



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    Copyright 2013

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    This e-mail and any files transmitted with it are confidential and are intended solely for the use of the individual or entity to whom they are addressed. This communication may contain personal patient health care information and is protected by federal law and other statutory protections. If you are not the intended recipient or the individual responsible for delivering the e-mail to the intended recipient, please be advised that you have received this e-mail in error and that any use, dissemination, forwarding, printing, or copying of this e-mail or any attached files is strictly prohibited. If you have received this e-mail in error, please promptly delete this message and notify the sender of the delivery error by e-mail or you may call Virginia Hospital Center -Arlington's Information Systems Department @703-558-6566.

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  • Hybrid, with some working from home 100% and some reporting to a brick &mortar. However, the reality is that w/ EPIC, all of our work is done off the units.

    Our clinicians do not chart on the units, they use this time on the units to work as clinicians, preferring to chart at home or in a dedicated break area, working in solitude. This factor with the Electronic Health Record means we have to schedule proactive meetings w/ key staff to perform education. Our staff do NOT want us 'at the elbow', and I understand why that is their preference.

    I believe a properly constructed query stands on its own merits, and the factors of finding and staffing rare talent (CCDS, CDIP) in a dense urban environment means Remote should be an option for some sites.

    We do periodically visit the units in order to review cases, and this increase our interaction with staff.



    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421



    evanspx@sutterhealth.org

    [cid:image001.jpg@01D16E14.5134C870]

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, February 23, 2016 8:07 AM
    To: Evans, Paul
    Subject: RE:[cdi_talk] Record Review in the Unites

    We are completely electronic now as well.
    We no longer go to the floors to review charts.
    We are able to work from home two days a week and are onsite three days a week.
    We have biweekly (every other week) meetings with a representative from each of our Hospitalists Groups.
    If we notice documentation trends that need addressed or Queries that aren't being answered we can bring them up then.
    The ability to work from home a few days a week is great!
    I think face to face time with physicians is important but I also think that can be accomplished if you maximize your onsite days.
    I'm hoping that eventually we may be able to work from home more often, but there is no plan for that at this time....
    GG

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, February 23, 2016 10:46 AM
    To: Goodman, Greta
    Subject: RE:[cdi_talk] Record Review in the Unites

    Does any other hospital out there also have work from home hours?

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, February 23, 2016 10:44 AM
    To: Debra L. Mullen
    Subject: Re:[cdi_talk] Record Review in the Unites


    We have a completely electronic EHR, working from home 1 day a week and my team works up on the floor (to increase visibility) 4-6 hours a week. They also do 'face-to-face' with the physicians when needed.

    Patty



    Patricia Matson Vitasinski RN CCDS

    Supervisor of Clinical Documentation

    Henry Ford West Bloomfield Hospital

    248 325-0204 office

    248 875-4969 cell

    email- pvitasi2@hfhs.org



    Please note new cell phone contact information



    ________________________________
    From: CDI Talk
    Sent: Tuesday, February 23, 2016 10:29 AM
    To: Vitasinski, Patricia
    Subject: [cdi_talk] Record Review in the Unites

    Hi Everyone,
    Those working in CDI with a complete electronic record, do you review records in the unites. If not, how often do you go to the floor (provide Face to Face time) in a week? Just would like to get an idea of the impact EHRs have had on CDI chart reviews.


    Sincerely,


    Stacey Butler, RHIA, CDIP, CCS, CCS-P
    Coding Manager, Hospital Coding & CDI
    Health Information Management Department
    Arkansas Children's Hospital
    1 Children's Way | Slot 109 | Little Rock, AR 72202
    501.364.1127 direct | 501.364.1152 office | 501.364.3968 fax
    butlers@archildrens.org



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    Copyright 2013

    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923

    ________________________________

    CONFIDENTIALITY NOTICE: This email contains information from the sender that may be CONFIDENTIAL, LEGALLY PRIVILEGED, PROPRIETARY or otherwise protected from disclosure. This email is intended for use only by the person or entity to whom it is addressed. If you are not the intended recipient, any use, disclosure, copying, distribution, printing, or any action taken in reliance on the contents of this email, is strictly prohibited. If you received this email in error, please contact the sending party by reply email, delete the email from your computer system and shred any paper copies.

    Note to Patients: There are a number of risks you should consider before using e-mail to communicate with us. See our Privacy & Security page on www.henryford.com for more detailed information as well as information concerning MyChart, our new patient portal. If you do not believe that our policy gives you the privacy and security protection you need, do not send e-mail or Internet communications to us.



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    Copyright 2013

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    CONFIDENTIALITY NOTICE: This email message, including any attachments, is for the use of the intended recipient(s) only and may contain information that is privileged, confidential, and prohibited from unauthorized disclosure under applicable law. If you are not the intended recipient of this message, any dissemination, distribution, or copying of this message is strictly prohibited. If you received this message in error, please notify the sender by reply email and destroy all copies of the original message and attachments.



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    **********************************************************************************************************
    This e-mail and any files transmitted with it are confidential and are intended solely for the use of the individual or entity to whom they are addressed. This communication may contain personal patient health care information and is protected by federal law and other statutory protections. If you are not the intended recipient or the individual responsible for delivering the e-mail to the intended recipient, please be advised that you have received this e-mail in error and that any use, dissemination, forwarding, printing, or copying of this e-mail or any attached files is strictly prohibited. If you have received this e-mail in error, please promptly delete this message and notify the sender of the delivery error by e-mail or you may call Virginia Hospital Center -Arlington's Information Systems Department @703-558-6566.

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  • Well said Paul! :)

    Juli

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, February 23, 2016 9:30 AM
    To: Bovard, Juli
    Subject: RE:[cdi_talk] Record Review in the Unites

    Hybrid, with some working from home 100% and some reporting to a brick &mortar. However, the reality is that w/ EPIC, all of our work is done off the units.

    Our clinicians do not chart on the units, they use this time on the units to work as clinicians, preferring to chart at home or in a dedicated break area, working in solitude. This factor with the Electronic Health Record means we have to schedule proactive meetings w/ key staff to perform education. Our staff do NOT want us 'at the elbow', and I understand why that is their preference.

    I believe a properly constructed query stands on its own merits, and the factors of finding and staffing rare talent (CCDS, CDIP) in a dense urban environment means Remote should be an option for some sites.

    We do periodically visit the units in order to review cases, and this increase our interaction with staff.



    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421



    evanspx@sutterhealth.org

    [cid:image001.jpg@01CE983E.025F5700]

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, February 23, 2016 8:07 AM
    To: Evans, Paul
    Subject: RE:[cdi_talk] Record Review in the Unites

    We are completely electronic now as well.
    We no longer go to the floors to review charts.
    We are able to work from home two days a week and are onsite three days a week.
    We have biweekly (every other week) meetings with a representative from each of our Hospitalists Groups.
    If we notice documentation trends that need addressed or Queries that aren't being answered we can bring them up then.
    The ability to work from home a few days a week is great!
    I think face to face time with physicians is important but I also think that can be accomplished if you maximize your onsite days.
    I'm hoping that eventually we may be able to work from home more often, but there is no plan for that at this time....
    GG

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, February 23, 2016 10:46 AM
    To: Goodman, Greta
    Subject: RE:[cdi_talk] Record Review in the Unites

    Does any other hospital out there also have work from home hours?

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, February 23, 2016 10:44 AM
    To: Debra L. Mullen
    Subject: Re:[cdi_talk] Record Review in the Unites


    We have a completely electronic EHR, working from home 1 day a week and my team works up on the floor (to increase visibility) 4-6 hours a week. They also do 'face-to-face' with the physicians when needed.

    Patty



    Patricia Matson Vitasinski RN CCDS

    Supervisor of Clinical Documentation

    Henry Ford West Bloomfield Hospital

    248 325-0204 office

    248 875-4969 cell

    email- pvitasi2@hfhs.org



    Please note new cell phone contact information



    ________________________________
    From: CDI Talk
    Sent: Tuesday, February 23, 2016 10:29 AM
    To: Vitasinski, Patricia
    Subject: [cdi_talk] Record Review in the Unites

    Hi Everyone,
    Those working in CDI with a complete electronic record, do you review records in the unites. If not, how often do you go to the floor (provide Face to Face time) in a week? Just would like to get an idea of the impact EHRs have had on CDI chart reviews.


    Sincerely,


    Stacey Butler, RHIA, CDIP, CCS, CCS-P
    Coding Manager, Hospital Coding & CDI
    Health Information Management Department
    Arkansas Children's Hospital
    1 Children's Way | Slot 109 | Little Rock, AR 72202
    501.364.1127 direct | 501.364.1152 office | 501.364.3968 fax
    butlers@archildrens.org



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    Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments.
  • I feel we review more records using EPIC than w/ paper..it was often difficult to find the paper record on the floor.

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421



    evanspx@sutterhealth.org

    [cid:image001.jpg@01D16E14.F317CE80]

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, February 23, 2016 7:29 AM
    To: Evans, Paul
    Subject: [cdi_talk] Record Review in the Unites

    Hi Everyone,

    Those working in CDI with a complete electronic record, do you review records in the unites. If not, how often do you go to the floor (provide Face to Face time) in a week? Just would like to get an idea of the impact EHRs have had on CDI chart reviews.


    Sincerely,


    Stacey Butler, RHIA, CDIP, CCS, CCS-P
    Coding Manager, Hospital Coding & CDI
    Health Information Management Department
    Arkansas Children's Hospital
    1 Children's Way | Slot 109 | Little Rock, AR 72202
    501.364.1127 direct | 501.364.1152 office | 501.364.3968 fax
    butlers@archildrens.org





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  • We are instituting Cerner as our EHR and moving onto 3M platform 2, so currently we are a hybrid system. I am the sole CDI for our facility and have been since 2011. I review all payers and on average do between 25 and 50 reviews per day. I do work remote one day a week and that will increase once we are 100% electronic. With the evolution toward electronic systems, to combat the decreasing face time, I elevated my visibility in many other ways. Presenting CMEs, joining several physician committees, attending the Hospitalist monthly meetings, publishing a newsletter, and steering many quality core measure projects, to name a few. In doing this I feel that I actually see the providers more, but in different settings, which prompts more discussion regarding the medical record.

    Overall this process has worked out very well.

    Amber L. Feighner RN MSN CCDS
    Clinical Documentation Improvement Analyst
    Blanchard Valley Health System
    1900 South Main Street
    Findlay, Ohio 45840
    P: 419-425-5787
    F: 419-423-5100

    [http://thecore.bvhealthsystem.org/upload/images/logos/BVHS.logo.Werheresignature350.jpg]

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, February 23, 2016 11:34 AM
    To: Feighner, Amber
    Subject: RE:[cdi_talk] Record Review in the Unites

    I feel we review more records using EPIC than w/ paper..it was often difficult to find the paper record on the floor.

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421



    evanspx@sutterhealth.org

    [cid:image001.jpg@01CE983E.025F5700]

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, February 23, 2016 7:29 AM
    To: Evans, Paul
    Subject: [cdi_talk] Record Review in the Unites

    Hi Everyone,

    Those working in CDI with a complete electronic record, do you review records in the unites. If not, how often do you go to the floor (provide Face to Face time) in a week? Just would like to get an idea of the impact EHRs have had on CDI chart reviews.


    Sincerely,


    Stacey Butler, RHIA, CDIP, CCS, CCS-P
    Coding Manager, Hospital Coding & CDI
    Health Information Management Department
    Arkansas Children's Hospital
    1 Children's Way | Slot 109 | Little Rock, AR 72202
    501.364.1127 direct | 501.364.1152 office | 501.364.3968 fax
    butlers@archildrens.org





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  • Thanks everyone for your responses. We would also like to offer our CDIS working from home options part-time, but we are fearful it will negatively impact provider engagement. Face to Face provider engagement has already been drastically reduced due to the EHR. The flyers in the work rooms and attending section meetings are great ideas in order to let the providers know we still exists.

    What other best practices are being used in order to keep providers engaged in the EHR environment?


    Stacey Butler, RHIA, CDIP, CCS, CCS-P
    Coding Manager, Hospital Coding & CDI
    Health Information Management Department
    Arkansas Children's Hospital
    1 Children's Way | Slot 109 | Little Rock, AR 72202
    501.364.1127 direct | 501.364.1152 office | 501.364.3968 fax
    butlers@archildrens.org

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, February 23, 2016 9:46 AM
    To: Butler, Stacey
    Subject: RE:[cdi_talk] Record Review in the Unites

    Does any other hospital out there also have work from home hours?

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, February 23, 2016 10:44 AM
    To: Debra L. Mullen
    Subject: Re:[cdi_talk] Record Review in the Unites


    We have a completely electronic EHR, working from home 1 day a week and my team works up on the floor (to increase visibility) 4-6 hours a week. They also do 'face-to-face' with the physicians when needed.

    Patty



    Patricia Matson Vitasinski RN CCDS

    Supervisor of Clinical Documentation

    Henry Ford West Bloomfield Hospital

    248 325-0204 office

    248 875-4969 cell

    email- pvitasi2@hfhs.org



    Please note new cell phone contact information



    ________________________________
    From: CDI Talk
    Sent: Tuesday, February 23, 2016 10:29 AM
    To: Vitasinski, Patricia
    Subject: [cdi_talk] Record Review in the Unites

    Hi Everyone,
    Those working in CDI with a complete electronic record, do you review records in the unites. If not, how often do you go to the floor (provide Face to Face time) in a week? Just would like to get an idea of the impact EHRs have had on CDI chart reviews.


    Sincerely,


    Stacey Butler, RHIA, CDIP, CCS, CCS-P
    Coding Manager, Hospital Coding & CDI
    Health Information Management Department
    Arkansas Children's Hospital
    1 Children's Way | Slot 109 | Little Rock, AR 72202
    501.364.1127 direct | 501.364.1152 office | 501.364.3968 fax
    butlers@archildrens.org



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    CONFIDENTIALITY NOTICE: This email contains information from the sender that may be CONFIDENTIAL, LEGALLY PRIVILEGED, PROPRIETARY or otherwise protected from disclosure. This email is intended for use only by the person or entity to whom it is addressed. If you are not the intended recipient, any use, disclosure, copying, distribution, printing, or any action taken in reliance on the contents of this email, is strictly prohibited. If you received this email in error, please contact the sending party by reply email, delete the email from your computer system and shred any paper copies.

    Note to Patients: There are a number of risks you should consider before using e-mail to communicate with us. See our Privacy & Security page on www.henryford.com for more detailed information as well as information concerning MyChart, our new patient portal. If you do not believe that our policy gives you the privacy and security protection you need, do not send e-mail or Internet communications to us.



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    CONFIDENTIALITY NOTICE: This email message, including any attachments, is for the use of the intended recipient(s) only and may contain information that is privileged, confidential, and prohibited from unauthorized disclosure under applicable law. If you are not the intended recipient of this message, any dissemination, distribution, or copying of this message is strictly prohibited. If you received this message in error, please notify the sender by reply email and destroy all copies of the original message and attachments.



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