Book excerpt: Conducting peer reviews
By Laurie L. Prescott, MSN, RN, CCDS, CDIP
Most likely you’ve already experienced peer reviews within your training; when you took your first record review and drafted your first queries, your manager or mentor looked over your shoulder and reviewed your work, offering you suggestions, guiding your efforts. Peer reviews work the same way, although they may be a bit more formal in function and execution.
Some CDI professionals worry about the intent of peer reviews and about potential punitive measures associated with mistakes uncovered. Nevertheless, the strength of ongoing peer-to-peer assessment lies in instilling not criticism but critique that leads to professional and communal growth as well as individual learning. For peer-to-peer audits to be successful, they must be used as a learning and evaluation tool. Their value comes from the ability of CDI staff members to learn from each other, to see what each other is doing, and support process improvement efforts.
Generally, CDI team members will be asked to review a random sample of five to 10 of each other’s charts and related queries per month, depending on the size and scope of the program. Reviews should include a cross representation of disease types and query reasons (e.g., specificity, legibility, lack of diagnosis). Reviews can either be done in a fun way, such as during a pizza lunch the last Friday of the month, or as a typical part of CDI staff members’ work week (with staff reviewing one or two peer records per week), so such efforts don’t interfere with productivity.
The point is to provide feedback regarding overall staffing strengths and weaknesses to the management but also to serve as a cross-pollination of sorts of team strengths and knowledge.
Each person has his or her own style, strengths, and foibles. For example, in reviewing a record regarding excisional debridement, one CDI specialist may read the record and see no query opportunities. Another CDI specialist may remember a Coding Clinic reference regarding excisional debridement and determine a query opportunity does exist. There may not be a right or wrong to this scenario, but in the course of the peer review, there is an opportunity for the two staff members to discuss their views and the various options open to them during the query process. Through that dialogue comes continued learning.
Editor’s note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.