Clinical Documentation Improvement

A Fresh Set of Eyes

This is the third blog in the series titled, 5 Benefits of Being a Traveling Clinical Documentation Specialist, and it’s all about you!

Part I | Part II | Part III | Part IV | Part V

You hold a skillset and experiences that no one is able to tap into, for they haven’t walked in your shoes. Even two people from the same workplace don’t walk away with the same reality, for work comprises less than 1/3 of your life; your observations and involvement with life during the remaining hours blend with your hours at work to create a unique you.

During the day, as you read, listen and watch, you are absorbing pieces of information that are constantly reshaping you. We are always learning and growing. During the day, you may have had a bit of a challenge in selecting the appropriate principal diagnosis on a particularly complex case, or perhaps you reach a point where you are stuck in the development of a presentation and then that evening, a nugget of information on the newscast finds its way to you, the lightbulb comes on, and you share that newly acquired knowledge with your peers the next day.

You are unique and your skillset is uniquely yours. When you are lucky enough to travel for a career, you bring your unique skillset to CDI teams at other facilities and create an atmosphere of sharing as you learn from each other. It’s difficult to figure out who is luckier to work in a face-to-face networking environment every day because otherwise they have to network from afar or wait until conferences to glean information about the latest and the greatest.

Is it the facility, who benefits from the insight on what others have found useful? Is it the established team, who benefits from hearing a fresh perspective on the interpretation of the latest Coding Clinic? Or is it you, the contract CDS, who has the satisfaction of knowing you are helping others, but also in learning some pearls of wisdom in a sharing environment that can be carried to the next facility? It is likely all three, isn’t it?

The benefit of bringing a fresh set of eyes to a facility as a Clinical Documentation Specialist is invaluable. For most undertakings in life, there can be multiple methods to achieve a goal as long as the basic principles are followed. In the Clinical Documentation Improvement profession, the one that comes to mind is query development.

While there are principles that must be followed, such as not leading the provider, the format of the query can be customized using several methods. Do you place the clinical indicators at the top or the bottom of the query form? Have you found a method of formatting the query so the provider will document their response in the medical record and not on the query form itself?

There are others that might seem commonplace to you, but they may have never heard of that great tip at the facility you are traveling to. By answering the facility’s request to look at their query formatting with a fresh set of eyes, you can bring recommendations by highlighting your unique query formatting method.

I want to end by letting you know is that I have worked for MedPartners, a top ranked staffing company, for almost 5 years, and traveled with them for 3 of those years. Because of my experience with traveling, I know without a doubt that considering traveling is a big step because I have been there, done that!

I want to share my email with you in case you have any questions about traveling CDI, or if something that you have read has piqued your interest and you would love to learn more. My mission is to set people up for success! Please don’t hesitate to contact me at knewhouser@medpartners.com

Respectfully,

Karen

Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP
Director of Education, MedPartners

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