I think a good CDS needs to be someone with a background in some type of critical care...icu/er. I also think they need to be a self motivated individual as well as a team player. They need to have a good rapport with the docs. Before I took my job as a CDS I had 9 yrs med-surg experience and 6 yrs ER experience. Soon learned what a challenging as well as rewarding position I took being a CDS.
Tracy M Peyton RN, CCDS Bradford Regional Medical Center Upper Allegany Health Systems 116 Interstate Parkway Bradford, PA 16701 814-558-0406
Ruthann Russo,PhD,JD, MPH, RHIT outlined the following characteristcs to look for in a potential CDS in her book, “Clinical Documentation Improvement: Achieving Excellenceâ€:
Work Experience in Acute Care Hospital Setting (That doesn't mean only Nursing experience) Critical Thinking Skills Poise; Confident Professionalism Excellent Interpersonal skills Outgoing Good communicator – Verbal & Written Self-motivated Ability to Multi-task Persistent – but not alienating Thrives on Challenge “Can-do†Attitude Passionate about the Program Enjoys Educating Others Creative
I find these to be excellent requirements in seeking candidates for hire or when interviewing potential CDS.
Here are some resources that I have found helpful:
1. Colleen Garry's book The Clinical Documentation Improvement Specialist's Handbook, chapter 2 , beginning on page 16 discusses things to look for when hiring a CDIS. 2. Marion Kruse did a 2nd edition of the above and chapter 4 has a section called Interview Techniques that also lists things to look for when interviewing/hiring. 3. Ruthann Russo's book Clinical Documentation Improvement Achieving Excellence, Chapter 6 page 64 gives some great characteristics too.
Sharon Cole, RN, CCDS Providence Health Center Case Management Dept 254.751.4256 srcole@phn-waco.org
Another thing I have learned when hiring is that you can train/teach CDI principles, coding, query writing. You cannot train personality and I do believe it takes certain personality traits to be a good CDI Specialist. I interviewed someone once who told me she was applying for this position because she was tired of putting up with the physicians she worked with and thought that "reviewing charts and writing queries" would be a job where she wouldn't have to deal with patients, families, other nurses, or physicians. She told me she didn't like speaking with physicians and wanted to stay in a quiet corner and just write the queries. She had coding and acute care nursing experience, was an RN and RHIT but thought that she could review charts and place queries without speaking to physicians or anyone else for that matter. She had the necessary qualifications and tons of experience but I didn't feel she would make a good CDIS.
Sharon Cole, RN, CCDS Providence Health Center Case Management Dept 254.751.4256 srcole@phn-waco.org
I agree Sharon. When I started I had never worked as a CDI, but had knowledge of the role. I had worked in case management and had a wide variety of other experiences, but the ability to work with others including the providers and coders is critical. If you can't communicate with others effectively how can you educate and have success in what you do?
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS Clinical Documentation Improvement Specialist Aleda E. Lutz VAMC Mail Code 136 1500 Weiss Street Saginaw MI 48602
I interviewed a man who said he was an MD in his country of origin and now a Manager in coding at his current facility. He knew all the Coding Guidelines and Federal Regulations like the back of his hand. However, he also "knew" that he was much more knowledgeable than the physicians about required documentation to meet compliance. His answer, when I posed a hypothetical question to him so I could assess his approach with physicians was, "I would tell him the requirements for ICD 9 coding and tell him this is what you need to write."
That was not the approach I was looking for. While I understand that we, as specialists in the field, for the most part, do in fact understand more than the physicians regarding documentation needs to reflect true severity and risk, communicating respect and a team approach towards a united goal can go a very long way in relationship building. Facts, figures and knowledge of rules is just that. It is one part of this job. And in my mind, not even the most important part.
Donna Kent, RN, BSN, CCDS Manager, Clinical Documentation Integrity Program Clinical Quality and Accreditation Torrance Memorial Medical Center ph.:310 784-6884 fax:310 784-6899 donna.kent@tmmc.com
Great comments. Something I ask is if they enjoy working puzzles - crossword, find a word etc type. I explain sometimes our chart reviews are like working a puzzle. Find the missing pieces, hidden words - you know the tips and clues thing.
Shelia
Shelia Bullock, RN, BSN, MBA, CCM, CCDS Director, Clinical Documentation Services University of Mississippi Health Care 2500 North State Street Room S 336 Jackson, MS 39216 T: 601-815-3079 F: 601-815-9505 sabulllock@umc.edu umhc.com
Something I have in a P&P -- not sure where I 'borrowed' this from...
3. Clinical documentation specialists possess knowledge of a wide range of specialized disciplines, a. including education in anatomy and physiology, pathophysiology, and pharmacology; b. knowledge of official medical coding guidelines, CMS, and private payer regulations related to the Inpatient Prospective Payment System; c. an ability to analyze and interpret medical record documentation and formulate appropriate physician queries; d. and an ability to benchmark and analyze clinical documentation program performance.
Also: * High level of expertise & success in their 'home' profession (BOTH Coding OR Nursing) * Persistent, type 'A' * Puzzle solver * Takes on challenges * Excellent communication & interpersonal skills * Independent with great team work skills * Good self-teacher, engaged learning/curiousity
Comments
Before I took my job as a CDS I had 9 yrs med-surg experience and 6 yrs ER experience. Soon learned what a challenging as well as rewarding position I took being a CDS.
Tracy M Peyton RN, CCDS
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
814-558-0406
Work Experience in Acute Care Hospital Setting (That doesn't mean only Nursing experience)
Critical Thinking Skills
Poise; Confident
Professionalism
Excellent Interpersonal skills
Outgoing
Good communicator – Verbal & Written
Self-motivated
Ability to Multi-task
Persistent – but not alienating
Thrives on Challenge
“Can-do†Attitude
Passionate about the Program
Enjoys Educating Others
Creative
I find these to be excellent requirements in seeking candidates for hire or when interviewing potential CDS.
N. Brunson, RHIA, CCDS
Key skills and competencies for those in CDI roles:
Knowledge of Coding Concepts & Guidelines
Clinical Terminology
Clinical Knowledge (Anatomy & Physiology, Pathophysiology, pharmacology)
Knowledge of Healthcare Regulations, reimbursement and documentation requirements
It would also depend on the type of program your facility supports - Hybrid Model or Single Discipline.
Ruthann's book is an excellent resource for CDI programs.
N. Brunson, RHIA, CCDS
1. Colleen Garry's book The Clinical Documentation Improvement Specialist's Handbook, chapter 2 , beginning on page 16 discusses things to look for when hiring a CDIS.
2. Marion Kruse did a 2nd edition of the above and chapter 4 has a section called Interview Techniques that also lists things to look for when interviewing/hiring.
3. Ruthann Russo's book Clinical Documentation Improvement Achieving Excellence, Chapter 6 page 64 gives some great characteristics too.
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
srcole@phn-waco.org
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
srcole@phn-waco.org
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
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
"We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley
That was not the approach I was looking for. While I understand that we, as specialists in the field, for the most part, do in fact understand more than the physicians regarding documentation needs to reflect true severity and risk, communicating respect and a team approach towards a united goal can go a very long way in relationship building. Facts, figures and knowledge of rules is just that. It is one part of this job. And in my mind, not even the most important part.
Donna Kent, RN, BSN, CCDS
Manager, Clinical Documentation Integrity Program
Clinical Quality and Accreditation
Torrance Memorial Medical Center
ph.:310 784-6884 fax:310 784-6899
donna.kent@tmmc.com
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
srcole@phn-waco.org
Shelia
Shelia Bullock, RN, BSN, MBA, CCM, CCDS
Director, Clinical Documentation Services
University of Mississippi Health Care
2500 North State Street
Room S 336
Jackson, MS 39216
T: 601-815-3079 F: 601-815-9505
sabulllock@umc.edu
umhc.com
3. Clinical documentation specialists possess knowledge of a wide range of specialized disciplines,
a. including education in anatomy and physiology, pathophysiology, and pharmacology;
b. knowledge of official medical coding guidelines, CMS, and private payer regulations related to the Inpatient Prospective Payment System;
c. an ability to analyze and interpret medical record documentation and formulate appropriate physician queries;
d. and an ability to benchmark and analyze clinical documentation program performance.
Also:
* High level of expertise & success in their 'home' profession (BOTH Coding OR Nursing)
* Persistent, type 'A'
* Puzzle solver
* Takes on challenges
* Excellent communication & interpersonal skills
* Independent with great team work skills
* Good self-teacher, engaged learning/curiousity
Lots of other great comments.
Don