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!
In the latest edition, we’re talking to Diana Cheng who leads the CDI team at North Metropolitan Health Service in Western Australia. Diana's clinical background and extensive experience as a coding auditor and educator enables her to be a strong and effective interface between clinicians and clinical coders.
Tell us about your current role
Clinical Documentation Improvement Specialist (CDIS) at North Metropolitan Health Service in Perth, Western Australia.
What is your career background, and how has that contributed to your ability to work as a CDS?
I was a medically trained doctor overseas and changed to clinical coding in New Zealand in 1998. I then became a senior coder in Melbourne Victoria from the early 2000s. I worked as a classification lecturer for 10 years at Latrobe University. I am also a qualified state external auditor in both Victoria and WA since 2006 and have been involved in state coding auditing activities in many hospitals. One of the major issues contributing to coding data quality and impacting on DRG/Casemix of inpatient admissions is inadequate quality of clinical documentation. My clinical knowledge and experience allow me to communicate with clinicians in a professional way; and my more than 20 years’ coding/auditing experience make me understand the comprehensive clinical documentation need for accurate coding. My university teaching experience empowers me with good skills in produce education material and deliver to all levels and fields of clinicians.
What made you apply for a CDS role?
With my skillset and knowledge, I always want to contribute in a way to help both clinician and coders. Especially when I got the feedback from the junior doctors that they have not received any formal education on clinical documentation with its applications in the health care system in both university education and on job education. I believe that I would be good fit for this type of role. When the opportunity came, I changed my role from a Senior Health Information Auditor at the Department of Health to a CDS.What does your typical day look like?
My typical day activities include:
What was the moment CDI really “clicked” for you?
When I worked as a senior coder in Victoria and needed to communicate with consultants constantly for coding related documentation queries. I start to realise the need of this role.
How would you describe your personal CDI philosophy?
Be the bridge to bring clinician and coders together for maintaining the quality and integrity of health data for patient safety and quality of care, for sustainability of health care.
What is the biggest challenge you have faced as a CDS?
Educating clinicians to take responsibility for good clinical documentation and to understand its importance for the quality of patient care.
What is the most memorable “win” you’ve had?
Providing education of the Casemix mechanism to senior doctors and gaining their trust. Seeing the documentation change in the Junior doctor’s notes from hardly anything documented in the progress notes to detailed diagnoses linked to plan/treatment.
Having more consultants willing to be involved in CDI.
If you could talk to yourselves 10 years ago and tell them you’re now a CDS, what do you think they would say?
They would say that I should have started as a CDS back then.
Favourite DRG?
Too many. I09A, B02A; K01A; I12A
Favourite additional diagnosis?
Anaemia; Hypotension; Delirium; UTI
What are you excited about in the future of your role?
Increase the awareness of importance of clinical documentation in health care services leading to a culture change.
Want to be the next CDS profiled on CDS Snapshot? Contact us at community@cdia.com.au.
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