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 this edition we’re talking to Kim Lewis, CDS for Bairnsdale Regional Health Service. Kim shares how she shaped this new role using her extensive nursing and quality improvement background, built strong cross-department relationships, and championed better documentation practices to support patient care. She reflects on her biggest challenges, proudest wins, and the ongoing impact of CDI in improving both clinical communication and organisational outcomes.
Tell us about your current role
I currently hold the newly established position of Clinical Documentation Specialist at Bairnsdale Regional Health Service (BRHS).
I work closely with all clinical teams to promote best practices in documentation by identifying opportunities for improvement, collaborating with staff to address documentation gaps, clarifying ambiguities, and providing education and support around documentation standards and requirements.
Being the first person in this role at BRHS, I’ve had the opportunity to shape the position, build strong relationships across departments, and lay the groundwork for long-term improvements in clinical documentation practices.
What is your career background, and how has that contributed to your ability to work as a CDS?
My professional background is grounded in over 30 years of clinical nursing experience in the medical/surgical areas and then with a focus as a Clinical Nurse Specialist in the Perioperative field. During the COVID-19 pandemic, when surgical services were significantly reduced, I transitioned into the role of a Hospital Coordinator.
This shift broadened my exposure to the wider health service and allowed me to develop a more holistic understanding of hospital operations and patient flow.
Around the same time, I accepted a position within the Quality Department as a Quality Coordinator, a role I have held concurrently for the past 5 years. Balancing both positions has given me valuable insight into continuous improvement initiatives.
This diverse background has been instrumental in my transition into the CDS role. My established relationships with medical, nursing, and allied health staff across the organisation have been key in setting up this new position and fostering collaboration. I already had a strong understanding of the organisational structure, culture, and workflows, which has enabled me to engage effectively, identify documentation improvement opportunities, and support meaningful change.
What made you apply for a CDS role?
In my previous roles, I regularly read medical records and consistently noticed gaps and inconsistencies in documentation. It became clear to me that poor or unclear documentation could impact patient care, communication, and overall service delivery. I often found myself thinking, "There has to be a better way to do this."
With my background and strong working relationships across departments, I felt I was in a unique position to contribute to positive change. When the CDS role was advertised, it felt like a natural next step, an opportunity to apply my knowledge and experience to help improve documentation practices across the organisation.
My goal in stepping into this role was to support better understanding of each patient’s presentation and care plan, not just for individual clinicians but for the entire care team. I genuinely believe that clear, consistent documentation is the foundation of safe, effective, and coordinated care, and I wanted to be part of driving that improvement.
What does your typical day look like?
A typical day involves a significant portion of my time reviewing patient medical records in the Electronic Medical Record (EMR) system, then updating my tracking spreadsheet with key patient details, documentation notes, and any queries or concerns I may have. If questions arise, particularly about diagnosis clarity, care plans, or clinical indicators, I reach out to relevant staff across the different disciplines.
If patients have been discharged, I often follow up with retrospective queries or reach out to the care team to clarify documentation for future improvement.
What was the moment CDI really “clicked” for you?
It took a few months to fully find my feet in the role, but there was a clear turning point when I began to see the changes I had been advocating for reflected in everyday clinical documentation.
Seeing clinicians take on board the feedback and education, and then apply those improvements in their notes, whether it was clearer diagnosis documentation, more precise language, or a better-defined care plan was incredibly rewarding. It showed me that the work I was doing was making a real impact, not just on paper, but on patient care and team communication.
That shift confirmed for me that with persistence, relationship-building, and consistent messaging, positive change is absolutely possible in how we document and communicate
How would you describe your personal CDI philosophy?
My approach is rooted in continuous learning and collaboration. I recognize that I am always evolving in this role, and each experience, especially the mistakes, has been an opportunity for growth and deeper understanding.
I believe that consistency in documentation across the organization is vital. When we are aligned and clear in how we communicate patient information, we improve care outcomes and support safer, more efficient teamwork. My goal is to contribute to a culture where accurate, thorough documentation is a shared responsibility, and where all staff feel informed, involved, and empowered to deliver the highest standard of care.
What is the biggest challenge you have faced as a CDS?
The biggest challenge I’ve faced is not having a formal background in clinical coding. While I bring strong clinical knowledge and experience to the role, there are times when I feel limited in fully understanding the coding implications of the documentation improvements I’m making, particularly when it comes to DRG groupings, or evaluating whether my queries are ultimately resulting in coding changes.
As a result, I often need to rely on our very busy coding team for clarification and feedback. They’ve been incredibly supportive, but I’m mindful of their workload and the time it takes to respond. This has highlighted for me the importance of ongoing collaboration between clinical documentation and coding, and it’s something I continue to learn from.
Despite this challenge, I remain committed to growing my understanding in this area.
What is the most memorable “win” you’ve had?
One of the most memorable moments was the first time I received confirmation from the coding team that one of my documentation queries had led to a DRG change that resulted in increased funding for the organisation.
While I fully recognise that the primary goal of CDI is to enhance patient outcomes through accurate and complete documentation, this moment felt like a significant milestone. It showed that the work I’m doing also contributes to the financial sustainability of the organisation.
Knowing that my efforts were making a tangible difference in multiple areas really affirmed the value of the role and the importance of CDI as a whole.
If you could talk to yourselves 10 years ago and tell them you’re now a CDS, what do you think they would say?
I don’t think I would have believed myself, actually I wouldn’t have even known what a CDS was! At that time, I was fully immersed in my role as a Perioperative Nurse, and genuinely thought that would be my long-term path.
COVID changed everything and the pause in elective surgeries forced me to step outside of my comfort zone and take on new roles. Those experiences opened my eyes to the broader workings of the health service and sparked an interest in improving systems and communication.
Now, in hindsight, it all makes sense. Each step helped build the foundation for this role. I’ve grown in ways I never expected, both personally and professionally.
Favourite DRG?
I would have to say DRG is E62, the pneumonia DRG. Bacterial pneumonia is a diagnosis that’s often under-documented, yet it can be relatively straightforward to identify. There’s a real sense of satisfaction in helping to bring it to light, knowing that doing so contributes to a more accurate clinical picture and appropriate coding, sometimes even moving a split from a B to an A.
That said, I also really enjoy investigating the different Respiratory Failure types. There’s a bit of detective work involved - reviewing pathology, imaging reports, and digging into observation charts to track oxygen saturations and supplemental oxygen use. Piecing everything together to support a clinical picture that may not have been clearly stated is both challenging and rewarding.
Favourite additional diagnosis?
I would say Anaemia is my favourite, Acute Blood Loss Anaemia is even better. I’m often surprised by how frequently patients receive blood products or iron infusions without anaemia being accurately documented.
Highlighting and improving the documentation around anaemia not only ensures that the patient’s condition is fully captured but also helps the care team understand the patient’s overall clinical status better. It’s a diagnosis that can easily be overlooked but has important implications for treatment planning and outcomes.
What are you excited about in the future of your role?
What excites me most is the opportunity to keep driving meaningful change and improvement. I’ve only just begun to scratch the surface of what’s possible, and I have many ideas I’m eager to implement.
I feel incredibly fortunate to have a supportive Executive team that has given me the freedom to shape this role from the ground up. That trust and flexibility have allowed me to be innovative and proactive in identifying areas for improvement.
One project I’m particularly excited about is working with the Internal Medicine Unit to reduce the reliance on copy-and-paste notes during daily patient reviews. A new documentation template is currently being developed that will replace this practice and promote clearer, more meaningful entries for all staff involved in a patient’s care.
Knowing that these changes can directly impact communication, care, quality, and patient outcomes is what motivates me every day.
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