Guest Post: A passion for patient care is vital for nurses making the transition to CDI efforts

by Dee Schad, RN, BSN, CCDS, CDIP

As a nurse new to the worlds of coding and clinical documentation, it can feel quite overwhelming.  Making the transition from the clinical side of nursing to a  non-traditional nursing role can be challenging.  To make that transition smoother, it may help to reflect back to your earlier days as a new nurse.

When choosing a career in nursing, most nurses say they made that decision because of a desire to help people.  Perhaps it was just a pure passion for caring.  In nursing school one quickly learns that there are a lot of technical skills combined with critical thinking skills required to be a nurse.  At some point in time many of us may have secretly ask: “What about the caring part? When do I get to take care of people?”

As a new nurse on the floor your duties quickly turned to mastering a variety of technical skills such as monitoring patients’ IVs and ventilators, providing wound understanding nursing computer software, EKGs, etc.  In those early days the idea of caring for patients seemed almost impossible as you struggled with all those technical challenges required for the day-to-day job.

As you matured into a seasoned nurse, you mastered the juggling act of technical and critical thinking skills and somehow managed to integrate caring into your daily patient care. At that point, you began to feel good again about the nursing profession.  Remember how rewarding it was when you finally mastered the technical skills, and were able to apply your critical thinking skills, and still find a way to go above and beyond for that special patient. Remember the moment when you finally realized that passion for your job that initially drove you to choose the nursing profession.

In my many years of working in clinical documentation I have found the journey to be very similar to my early days as a nurse.  When considering the career move into the role of a CDI specialist, you find the goal of the program is capturing accurate documentation in the patients chart to reflect true patient acuity, severity of illness/risk of mortality, and to ensure the physician and the hospital receives appropriate reimbursement for the resources used to care for our patients.

Wow…it is all about helping people…Sounds great!  Sign me up!

As with those early days in the nursing role, so too with professionals transitioning to CDI efforts; the job can seem very technical and mechanical at first. There is a whole new language to learn; ICD-9, DRGs, principal diagnosis, co-morbid condition, CC, MCC, data abstraction, queries, excisional/non-excisional, etc.

It is easy to get caught up in the mechanics of CDI. It is easy to lose the vision of why we choose to come to this profession.

It is imperative that that we don’t stop when we master the technical side of CDI, the mechanics. Taking clinical documentation to the next level will bring you success as a CDI specialist and take your facility’s program to new heights.   It is important, as with nursing, to take time to reflect on why you chose this profession.  When you are reviewing a chart, don’t stop investigating when you get the right DRG.  Step back and take a real good look at how sick the patient is, compare that with the physician’s documentation to determine if it is sufficient. If the documentation does not capture the severity of illness of that patient, does it really matter if you identified the DRG?

If you find yourself at that point where you are finally beginning to feel comfortable with your CDI technical skills, I challenge you to elevate your efforts to the next level.  Have that face-to-face with the physician, research that disease process further, call in your physician advisor for additional input, go above and beyond to get your documentation.

I promise it will feel good. You will remember why you chose this role. You can make a difference. When you do, you will find a renewed passion for the CDI profession.

Editor’s Note: Dee Schad, at the time of this article's original release, was Director Care Coordination and CDI at Clark Memorial Hospital in Jeffersonville, Ind., and a 2012 inductee to the ACDIS Advisory Board.