New CDI w/questions on provider education

Snuggs105Snuggs105
in General
HI Guys!

I am brand new to CDI and my manager is asking me to contribute to provider education at the end of the month.  I work at a teaching hospital and this presentation will be given to the residents who are doing most of the documentation. This will be the first time the CDI department has made a presentation to the staff..

I am struggling with topics. It was suggested that I use examples from daily reviews. How do you educate your residents at your hospital?

What I mostly struggle with as a CDI is ?dx and when they use vs. with several different diagnosis (illus vs. sbo vs. constipation etc. ). They do not rule out these diagnosis they simply drop from the record, or they're transferred out of the ICU to the floor and the doctor does not pick it up on their report. Do you run into this problem often, is there a secret code on how to decipher this :)

Any advice is appreciated :)

Comments

  • JSandRNJSandRN
    I do a monthly presentation for ICU residents. The DDx issue is one that I touch on frequently. I stress the importance of ruling in/out DDx, especially in the transfer of care note or DC summary. I also stress documenting POA status for potential HACs, Copy and paste habits, linking when necessary for code assignment, specificity and acuity for common Dx seen in that unit (resp failure, CHF, etc.) as well as making sure each medication/tx has a corresponding diagnosis somewhere in the documentation.
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