CDI peer review audit tool
Does anyone have a CDI peer review audit tool that is more robust than just focusing on queries? While the query aspect is important, there is more to the job than that. If I don't have to reinvent the wheel I'd appreciate any help you all can share.
Thanks,
Donna
Thanks,
Donna
Comments
Another Donna :-)
fishdl@shands.ufl.edu
By having specific questions, with essentially Y/N/NA as only answers(all questions are intended to be worded such that the 'good' answer is Yes), it is designed to load the review data into a database and then calculate percentages for an entire team as well as for the individual CDS. I like percentages, graphs, trends over time, comparison, etc. Also helps to set standard levels of performance.
Several of the questions do not include all of the reasonable options (such as the reasons for a query -- question #9) however in those cases, existing P&P as well as the AHIMA briefs should be considered incorporated in full detail when auditing the record.
For questions 3 & 15, the sub-set questions are N/A unless the initial question is No, in which case are able to drill down more specifically to what are the issues.
Though not specifically identified as references on the tool itself, consider both of the AHIMA briefs as cited references, as well as my / your organization P&P -- and we all have those, right?
If you have a large enough team and opt to do peer reviews, then having each record reviewed independently (and blindly) by 2 CDS's allows establishing inter-rater reliability. If there is significant disagreement on any one case, then should be referred to manager for final review.
If one is a single person shop, then either consider if there is a strong person in Coding, compliance, etc. who could do an audit, or at the very least, do self audits.
Audit's can be performed in a variety of ways, consider: peer to peer, leadership, compliance, coding... depends on resources, size, expertise.
PLEASE, make sure that you edit this to reflect your own needs and most importantly, your P&P.
There is a white paper, as well as a ppt on Auditing available (given at a NC ACDIS meeting)
The PPT in Forms & Tools: Butler Auditing Tool http://www.hcpro.com/content/279047.ppt
A link to the white paper: http://www.hcpro.com/content/268350.pdf ; http://blogs.hcpro.com/acdis/2011/07/white-paper-audit-your-cdi-program-to-avoid-pitfalls/
LOVE to hear feedback & suggestions!
Don
Wendy R. Chenney RN BSN
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Parma Community General Hospital
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Oh yea, and to any Veteran's out there. Happy Veteran's Day and thank you for your service.
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Former Major, U.S. Army Nurse Corps
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Robert
Don
Donna
Robert - A word of thanks to all of our Vets and to the VA. I am an ARMY vet and I obtained by RHIA B.S. via my VA educational benefits...I proudly served in the U.S. Army in a Medical Unit. The experience was invaluable. I would never have funded my success w/o having served.
Paul
Paul Evans, RHIA, CCS, CCS-P, CCDS
Paul Evans
Paul Evans, RHIA, CCS, CCS-P, CCDS
We are indebted to our veterans for the freedoms we still enjoy.
To all who served, Thank-you.
Charlene
Thank you to you and your fellow vets. You are very much appreciated and I don't believe you all receive the credit you deserve.
Francisca Wojciechowski, BS, RHIA, RHIT, CCDS
AHIMA-Approved ICD-10-CM/PCS Trainer