Retiring clinical documentation specialist looks back
29 Aug 2021From sticky notes to EMR and working remote
By: Coleen Elser RN, CCDS
I have been working in CDI (Clinical Documentation Integrity) at Salem Health for 15 years and it is now time for me to retire. Before I do that, I wanted to take a moment to look back at all the changes within CDI.
The name itself, for instance: We started as Clinical Documentation Improvement; in 2020 we made the switch from ‘Improvement’ to ‘Integrity’ as this is a better representation of our work and our goal.
CDI started in the days of paper charts and we would leave actual sticky notes on those charts with our queries attached. We then had to later locate that chart and interpret the hand-written query response that would come from the provider. Then along came electronic medical records and Epic, which had us typing queries into virtual yellow sticky notes. No more searching for paper charts and decoding hand-written responses! Yeah! As we moved into the computer age, CDI went from being under Care Management to being under HIM, which splintered our tiny group. We started over from scratch and have rebuilt into a very cohesive team, working closely with the Medical Coders.
As our small team started to feel comfortable in our role as CDS’, along came more big changes. ICD-10 was a huge undertaking for not only CDI but for all of our providers. Together we tackled understanding what ICD-10 would mean in our working lives. We all had questions but we sought the answers together — and together, we survived! Then, this past 18 months we have been dealing with the pandemic. COVID-19 has brought us all to the brink, with new codes and new signs and symptoms to understand, not to mention the massive amount of hard work put in by every Salem Health employee; and now it sure feels like we’ve settled into a new normal.
The CDI team has been almost entirely remote for the past five years. In this day and age of telecommuting, we know we in CDI will not be faces you recognize. Our hope is that our goal is both supported and recognized by all of our providers, and that, while we may be physically gone, we are not forgotten.
I will miss you all, but I know I leave you in solid, capable hands. The CDI team is strong and has the best interest of our patients, Salem Health, and our providers at heart.