How to have productive clinical discussions

Clinical documentation improvement (CDI) is about having effective clinical discussions that change behaviours – it is NOT about telling doctors what to write.

It is not uncommon for a well-meaning doctor to ask their clinical documentation specialist (CDS) what to write in the patient record, thinking it saves time and ensures the process is more effective.

But, like all health professionals, a CDS is bound by certain ethical standards. According to the Health Information Management Association Australia (HIMAA) clinical coding practice framework, a CDS cannot lead clinicians to document a specific diagnosis in the patient record.

That means a CDS cannot tell a doctor what to write or instruct them to write certain diagnoses that are implied but not explicitly stated in the patient’s record.

The clinician who ordered the treatment or test is the only person who can provide a missing diagnosis or link a diagnosis to a treatment and result.

Instead, the CDS needs to: 

• have regular conversations with clinicians to ensure they have captured and documented the true patient story, and
• educate clinicians on how to improve their documentation processes to enhance inter-clinician communication, and to ensure the capture of more accurate patient data.
   

CDI is, at its core, a behavioural change process that involves encouraging clinicians to change their way of thinking and habits for more effective documentation. CDI bridges the gap between documentation practices and coding to capture the true patient story.

 “Tell me what to write” is the wrong approach

Asking to be told what to write is a bit like a cry for help – it is a clinician’s way of expressing confusion, frustration, or misunderstanding.

A clinician who asks a CDS what they should write may not necessarily understand the impact of their documentation for improving patient safety, how coding and DRG assignment works, or the motives and philosophy behind the CDI program.

Clearly communicating the objectives and benefits of the CDI program helps to reinforce the CDI message and ensure all clinicians are on board with the new approach.

How to have good clinical discussions

It is the clinician’s decision to document the diagnosis, but it is a CDS's role to help encourage that diagnosis and a offer a different way of thinking. You can do this by:

• Asking questions that allow the clinician to bring the information forward – ask them why they gave a patient a treatment (for example, why they were administered the blood transfusion).
• Explain why you need a documented diagnosis – give reasons that reinforce your program’s objectives, like accurate and complete data, and better communication between healthcare workers.
• Discuss the entire clinical picture – you can then work with the clinician to determine if further specificity or a stronger link is needed.
• Keep communication open – be available when clinicians have questions and respond to queries as soon as possible.
• Foster trust – when clinicians trust you, they are more likely to be open to new ways of working.
• Call on your steering committee for support – key members of your CDI steering committee can help reinforce the CDI message.
• Explain the reason for CDI – make sure clinicians are aware of the reasons and benefits of the CDI program.

If you are seeking further strategies for working with clinicians to get buy-in for your CDI program, contact CDIA. We can help you set up a CDI program, or enhance your existing program.

We invite you to share your ideas, experiences, and achievements in CDI by submitting content to the CDIA Community!  Contact community@cdia.com.au to learn more.