I was asked to start the program at my facility in Aug 2010. I came from a case management position. 1 of our sister facilities already had a program in place so that was a big help. What I did was A LOT of research on the internet and the ACDIS website is my best resource. Also check with you HIM dept to see if they subscribe to "For the Record" and "Just Coding." First and fore most you should attend the CDI Boot Camp. I learned so much from that training. I am also attending the conference for the 1st time and I am very excited about it. We did not hire a consultant firm so our program is home grown. Best of Luck! Feel free to contact me anytime!
Dawn M. Vitalone, RN Clinical Documentation Improvement Specialist Community Hospital Munster, IN 219-513-2611
Be patient with yourself, it really takes a while to "get it"!
Be good friends with your coders, they are a wealth of knowledge.
And, keep on your clinical hat. I find that sometimes I just need to step back and think for myself "what is really going on with this patient", and then take another look for the clues in the record.
Maintain your professional relationship with the physicians, and don't be afraid to get your questions (clarifications) out there.
Lastly, look for severity, and the dollars will follow (just in case your program is $ focused...).
Welcome to the group. There is a lot of information here on the listserve and feel free to ask questions. The ACDIS site is also a great resource. I started the program here but worked at a hospital previously where they had a CDI program so was able to job shadow a little before coming here. I also came from case management and that was good background too.
My advice is if you have questions ask. There is a lot of expertise in this group and I know it has helped me a lot. Another thing I would do is to work on educating providers as to why you are doing what you are doing. They may think you are after the money, but for me my focus is and continues to be continuity of care and a complete and accurate medical record.
Good luck and don't forget to have fun too!
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
You've received a lot of great advice... take advantage of all available resources, ask questions, be patient with yourself, have fun... I also started our CDI Program from scratch without the assistance of a consultant. Our first tracking/reporting tool was homegrown (Excel spreadsheet) and I was the only reviewer for the first year and a half. Six years later, we are a team of four and have recently received approval to hire four more CDI Specialists. So again, be patient (and persistent). A bit more advice - if you have a State ACDIS Chapter, attend their meetings. Someone else mentioned shadowing or making a site visit to a hospital with a well-established CDI Program. I couldn't agree more! Several years ago, we hosted a site visit (three days) for two future colleagues from a neighboring state. It was a great experience for all involved! If you're planning to attend the ACDIS Conference in April, perhaps you would consider extending your time in Florida and arrange a site visit/shadowing experience with one (or more) of our outstanding ACDIS Florida Chapter members. Best Wishes. Donna Fisher, CCS, CCDS Shands at the University of Florida
I 'second' the recommendations given by the previous posters.
I have learned TONS by reading this message board on a daily basis. Also, I recommend the Exam Study Guide and CDS Handbook. I purchased those when I first started the job and found them helpful. I participated in the online bootcamp a few months ago and found it to be a good refresher while helping me progress to the next level.
And I've got to give a shout out to my local chapter leaders. Check to see if you have a chapter in your state. These groups are a great way to meet with other CDI specialists and talk about your concerns and come up with new ideas. Welcome! Welcome! And lots of luck!
Comments
Dawn M. Vitalone, RN
Clinical Documentation Improvement Specialist
Community Hospital
Munster, IN
219-513-2611
Be good friends with your coders, they are a wealth of knowledge.
And, keep on your clinical hat. I find that sometimes I just need to step back and think for myself "what is really going on with this patient", and then take another look for the clues in the record.
Maintain your professional relationship with the physicians, and don't be afraid to get your questions (clarifications) out there.
Lastly, look for severity, and the dollars will follow (just in case your program is $ focused...).
listserve and feel free to ask questions. The ACDIS site is also a
great resource. I started the program here but worked at a hospital
previously where they had a CDI program so was able to job shadow a
little before coming here. I also came from case management and that
was good background too.
My advice is if you have questions ask. There is a lot of expertise in
this group and I know it has helped me a lot. Another thing I would do
is to work on educating providers as to why you are doing what you are
doing. They may think you are after the money, but for me my focus is
and continues to be continuity of care and a complete and accurate
medical record.
Good luck and don't forget to have fun too!
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"The difference between the right word and the almost right word is the
difference between lightning and the lightning bug." Samuel "Mark Twain"
Clemens
resources, ask questions, be patient with yourself, have fun...
I also started our CDI Program from scratch without the assistance of a
consultant. Our first tracking/reporting tool was homegrown (Excel
spreadsheet) and I was the only reviewer for the first year and a half.
Six years later, we are a team of four and have recently received
approval to hire four more CDI Specialists. So again, be patient (and
persistent).
A bit more advice - if you have a State ACDIS Chapter, attend their
meetings. Someone else mentioned shadowing or making a site visit to a
hospital with a well-established CDI Program. I couldn't agree more!
Several years ago, we hosted a site visit (three days) for two future
colleagues from a neighboring state. It was a great experience for all
involved!
If you're planning to attend the ACDIS Conference in April, perhaps you
would consider extending your time in Florida and arrange a site
visit/shadowing experience with one (or more) of our outstanding ACDIS
Florida Chapter members.
Best Wishes.
Donna Fisher, CCS, CCDS
Shands at the University of Florida
I 'second' the recommendations given by the previous posters.
I have learned TONS by reading this message board on a daily basis. Also, I recommend the Exam Study Guide and CDS Handbook. I purchased those when I first started the job and found them helpful. I participated in the online bootcamp a few months ago and found it to be a good refresher while helping me progress to the next level.
Hope this helps.
Kim
Best Wishes!
Leah Taylor,RN, CCDS
NC ACDIS President
Iredell Memorial Hospital
557 Brookdale Drive
Statesville, NC 28625
E- leah.taylor@iredellmemorial.org
p- 704-878-7436
Welcome! Welcome! And lots of luck!