In CDS Snapshot, we're profiling CDSs from across Australia and ICD-10-AM countries. We'll get to hear how they got into the role, their triumphs, and challenges they've faced. CDSs contribute enormously to patient safety, quality of care, health service sustainability, and CDI as a whole, and we want them front and centre!
This time, we'll be getting to know Marie Hall, a Level 1 Certified CDS. Marie works in the Central Queensland Hospital and Health Service.
Tell us about your current role.
I work in the role of CNC Informatics at Rockhampton Hospital. This involves working in the CDS capacity across Central Queensland Hospital and Health Service, so my role takes in Emerald and Gladstone hospitals too.
What is your career background, and how has that contributed to your ability to work as a CDS?
My major clinical nursing experience has been in Midwifery and Child Health, although I have taken some detours along the way including Nurse Navigator, Cardiac Rehabilitation and Quality, Risk and Safety. I have also worked in a Business Management role for Telstra Health and Medibank Health Solutions for a start-up telehealth service called Anywhere Healthcare. Through these roles I have a broad exposure to change facilitation and managing relationships across health care streams whilst needing a broad, contemporary clinical knowledge base and an eye for detail.
What made you apply for a CDS role?
Some of my roles involved close scrutiny of charts for medico legal reasons, so when I saw the opportunity to improve documentation I was keen to know more. When I found out the role could influence funding for the work we do everyday I was more than enthusiastic.
What does your typical day look like?
A typical day involves reviewing inpatient records, identifying queries, pursuing clinicians to clarify verbal queries, or making written queries for patients that have already been discharged. I follow up with coders to discuss retrospective queries that need to be recoded. I try and educate as I go and provide tips but also there is a lot of formal education which is mostly negotiated to tie in with time that is already sequestered for clinical education or reviews.
There is always something new to understand, whether it’s a disease or treatment that I’m not up to date with or learning about all the cogs in the health system. I enjoy considering how best to interface with these systems to improve patient safety and outcomes through appropriate documentation and reimbursement for the care given across our health service. Involvement with committees, form review and state-wide guidelines allows me to contribute the CDS perspective to a wider community.
What was the moment when CDI really “clicked” for you?
Staff across the service have a hunger for this information: clinicians want to understand how to make documentation complete on a background of ensuring safe care for our patients and appropriate funding. So when I saw the enthusiasm from other clinicians I was hooked! So often clinicians wonder if we are getting funding for our complex clients, CDI provides the opportunity to be a dynamic force in quality communication and service sustainability.
How would you describe your personal CDI philosophy?
There’s so much room for improvement but together we make a seismic shift both in safe communication and appropriate reimbursement. As a nurse CDS we actually hold a body of knowledge that is unique in the health service, we have our professional clinical knowledge and an understanding of coding and funding.
What is the biggest challenge you have faced as a CDS?
Working in a non ieMR site but also having a number of stand alone digital platforms used throughout the service has been a huge challenge in looking at the complete documentation for an episode of care. Phases of care in one episode might be recorded across four different formats so it is difficult to easily view the whole patient journey and assess the completeness of documentation.
What is the most memorable “win” you’ve had?
When a staff member told me they were now using DUE TO in their personal text messages! Its such a great phrase.
If you could talk to yourself 10 years ago and tell them you’re now a CDS, what do you think they would say?
Good luck with that!
I12C…always so much opportunity for improvement!
Favourite additional diagnosis?
It’s a toss up between immunocompromised and uterine atonia. And then there’s newborn feeding problems. So many ADs to find!
What are you excited about in the future of your role?
There is so much to learn, and opportunities to share and expand the role across the health service, whilst also dovetailing with the other important work that is happening to ensure service stability and sustainability into the future.
Want to be the next CDS profiled on CDS Snapshot? Contact us at firstname.lastname@example.org.
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