Book excerpt: Shadow experienced staff to learn the CDI ropes

By Laurie L. Prescott, MSN, RN, CCDS, CDIP, CRC

Often, the first step getting started in CDI in becoming comfortable with the record review process is simply shadowing existing CDI staff members. If you are the first and only CDI specialist in your facility, reach out to ACDIS via its “ACDIS Forum” network or local chapter events. Consider calling nearby facilities and asking for their CDI department manager. Many CDI specialists willingly open their doors to those just starting out. If your CDI manager is willing (or has connections of his or her own), perhaps you will be able to shadow a neighboring facility to get a better idea of how different CDI programs function as well.

Many CDI program managers ask candidates to do this during the interview process so the potential staff member better understands the basic competencies and expectations of the job. Once hired, many program managers gradually introduce new CDI specialists to the process by shadowing experienced specialists at least once per week for a set number of hours or records per day.

First sitting alongside your CDI manager or mentor as he or she reviews a variety of common diagnoses. Where larger teams exist, consider rotating such shadowing experiences and taking note of how different individuals’ experiences and strengths affects how they conduct their reviews. Also, arrange time to shadow an experienced inpatient coder as well. You will find each person has his or her own method, and no method is necessarily better than the next.

When shadowing fellow employees during their record review process, consider asking the following questions.

• Where in the record do you start and why?
• What do you find provides you with the most information?
• What is a “must review” piece of documentation?
• Where are the hidden goldmines?
• How do you identify what is important to write down, track, etc.?
• How do you determine when a repeat review is needed?
• How do you determine if no further review is needed?

Editor’s note: This article is an excerpt from The CDI Specialist’s Complete Training Guide, Second Edition.