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 John Gale, Network CDI Manager at Southern NSW LHD.
Tell us about your current role
I am the Network Clinical Documentation Manager for Southern New South Wales Local Health District.
What is your career background, and how has that contributed to your ability to work as a CDS?
As a Nurse Manager I managed a Subacute Hospital in Goulburn NSW for 18 years. I have also had 2 private health related businesses.
What made you apply for a CDS role?
As a health manager I was constantly asked to reduced expenses and be financially more efficient. But knew that there was opportunity to better capture accurately the work that we did. I worked with a team to scope out the severity of the issue and was in a position to take up a role looking at strategies towards improving the districts NWAU capture.
What does your typical day look like?
My typical day includes meeting with clinicians, reviewing patients notes and working with the CDI team.
What was the moment CDI really “clicked” for you?
Understanding the relationship between accurate Clinical documentation and the care of the community we serve.
How would you describe your personal CDI philosophy?
“Build the field and they (the NWAU) will come (from the movie Field of Dreams).
What is the biggest challenge you have faced as a CDS?
Making clinical staff aware and understand that clinical documentation is a form of communication that if not used correctly will have repercussions for the care their patients receive.
What is the most memorable “win” you’ve had?
We didn’t have a CDI program until 2023 so our big win would be getting the program up and running with executive sponsorship and buy-in.
If you could talk to yourselves 10 years ago and tell them you’re now a CDS, what do you think they would say?
Your still alive! I didn’t expect that. You’re a CDS what’s that??? What’s an NWAU?????
Favourite additional diagnosis?
What are you excited about in the future of your role?
Making sure we stay abreast of any changes as they happen and how we can design AI to assist from the formulate phase.