Chart review without CDI software

JSandRNJSandRN
in General

Hi folks,

I am starting a new project in which I will be doing CDI review for a hospital that does not have CDI specific software. They rely on spreadsheets to record query impacts and productivity,but to my knowledge, they do not have a means to record findings, schedule follow ups, etc. I'm used to having 3M 360, so am struggling to figure out how to organize and keep track of my daily workflow. I may try to piece together an excel file but not sure how that would work out? I am wondering if anyone works in this type of environment and how do you track everything? If you have an example of an excel file or something that you use and can share, I'd appreciate it!

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Comments

  • teiwakik@icloud.comteiwakik@icloud.com

    Hi all

    I am also doing CDI work with no software in place. I would appreciate if anyone would share ideas on how to record findings queries follow up etc.

  • sreenathrdsreenathrd

    Good evening,

    I see you are talking about implementing CDI without software. We are in the process of building a CDI prototype software for small to medium and rural hospitals which cannot afford expensive CDI tools in the market. Let me know if you are interested in connecting me with your hospitals. We offer initial free software services for few months and once they see value, we get into business agreement.

    I can also offer free initial CDI physician advisory services as well. Let me know if you are interested. you can reach me at sreenath.meegada@megohealth.com

    Sreenath Meegada MD MPH CCDS.

  • lharbisonlharbison

    Hi,

    I came into CDI before we had truly CDI specific software like 3M 360. Which is a really nice tool.

    We would use review sheets. Then the review sheets would be placed in files, one for review tomorrow, or Tuesday, or Wednesday and so on. When the patient was discharged, the review sheets would be placed in a file where we saved them in case there was any question about the review itself.

    I don't have copies of those sheets anymore, but I think there might be a sample in the ACDIS files. I'll go check and see what I can find and post them here if I find them. I know it seem archaic, but it worked. You could do this same thing on the computer if you just save your review sheets to files on the computer.

    Make a file for reviews, and in that file put sub files for the days of the week they should be saved in. Then when you are done with your review, save the record to the next file. Then when you are done with the patients record for good, move it to a file with the d/c date. This way you have historical data.

    You can save your reviews in an excel file as well. just copy and paste the record ID number, admit date, review dates, DRG, query type, response, and d/c date and anything else you think of there for data collection from your review sheet. your review notes will be on the review sheet. You can make the fields on the review sheet match the excel file so copy and paste to the excel file will not be as cumbersome as typing it all out.

    I hope they are allowing time in productivity for the extra manual work. It seems they should be.

    Lori Harbison

  • lharbisonlharbison

    I wasn't able to find anything quickly and I have to get back to work, but I'm sure someone here will have an example, or you can just make one up for yourself!

    Best of luck.

    Lori

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