Dear Santa: Help me find a way to stop wasting time on charts

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Sitting side by side with a Clinical Documentation Specialist last week reviewing some records, I realized how much I hate reviewing a record and finding no reason to query. For me, the joy in CDI is finding the unspecified, the unwritten or even the undiagnosed. To me, this is how I’m able to utilize my knowledge and clinical expertise to support improving the quality of patient care. How often have you spent fifteen to twenty minutes searching through a record only to determine that there is not a query opportunity?

You end up reviewing hundreds of data points in the record yet find no clinical indicators to support a compliant query. Maybe the physician was having a slow day and remembered to include all the diagnoses being monitored and treated and even specified each diagnosis thoroughly. Or maybe the documentation is so vague and not enough results are back that a compliant query is not needed. Either way, you’ve just wasted 15-20 minutes of time that could be better spent in a record with documentation opportunities. Question is, how can you quickly and easily find the records with documentation opportunities?

Sitting side by side with a Clinical Documentation Specialist last week reviewing some records, I realized how much I hate reviewing a record and finding no reason to query. For me, the joy in CDI is finding the unspecified, the unwritten or even the undiagnosed. To me, this is how I’m able to utilize my knowledge and clinical expertise to support improving the quality of patient care. How often have you spent fifteen to twenty minutes searching through a record only to determine that there is not a query opportunity?

You end up reviewing hundreds of data points in the record yet find no clinical indicators to support a compliant query. Maybe the physician was having a slow day and remembered to include all the diagnoses being monitored and treated and even specified each diagnosis thoroughly. Or maybe the documentation is so vague and not enough results are back that a compliant query is not needed. Either way, you’ve just wasted 15-20 minutes of time that could be better spent in a record with documentation opportunities. Question is, how can you quickly and easily find the records with documentation opportunities?

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