CHIMA member Heather Nelson shares her perspective on clinical documentation improvement

CHIMA member Heather Nelson shares her perspective on clinical documentation improvement

BCYT member Heather Nelson lives in Prince George, BC with her husband and two dogs. An HIM professional with Northern Health, Heather took time to share with us about her experience in the 3M/CHIMA CDI program.

What interested you about the Clinical Documentation Improvement (CDI) Specialist Certificate Program?

When I was an HIM coder, I could see the potential for more accurate clinical documentation. Surely, pneumonia could be better specified than NYD. I could see that it could be expanded upon, but I didn’t know how I, as one person, could make that difference. When I saw that this program became available with CHIMA and 3M, I got super excited! I knew what this meant—it meant that change is coming! It meant that I could take part in making a difference in improving health information through clinical documentation.

Why is clinical documentation important?

Accurate documentation has such a significant ripple effect that it can’t be any more important. True clinical documentation is essentially the answer to providing the utmost care we, as health professionals, can possibly give. Improvement in our clinical documentation is paramount and potentially bears control on the entire health care system as a whole.

Tell us about your experience. What did you enjoy most about the program?

I found the program extremely interesting! I enjoyed it so much that when 3M and CHIMA offered a refresher program for preparation for the certification exam, I jumped on the opportunity! I found each module well laid out, content on key, and an abundance of learning material. Previously being a nurse and now a HIM professional, I found this program understandable and relating to everything we do in health information management.

I found the knowledge checks throughout very helpful because the modules were quite extensive in length and I was able to keep my learning (or refreshing) in check. I also found the test questions at the end were well written and always pertained to the material taught. The only suggestion I would make here would be to make more module test questions/answers. With the modules being so large, 10 test questions didn’t always seem enough to base on a full understanding of what was covered.

How has the program influenced your work?

After completing the program, I notice how clinical documentation can be improved in not only acute care, but also community care. It is such a huge part of health information that it can be very influential. With the right tools, training, and expertise, it has the capability to change the quality of patient care for the better.

What do you see for CDI and the future of health care?

The importance and need for good quality clinical documentation is growing exponentially every day. It’s a fundamental part of health care and will be well integrated in every aspect of it in the future. One day I hope to see a specialized CDI program be applied to physician and nursing education programs (I’d love to be the teacher!). It would be great to see this awareness implemented early into our future medical professionals’ training and education. The outcome will be that our patients will be better taken care of through accurate clinical documentation.

What would you say to someone who was interested in the program?

I highly recommend this program for HIM professionals, doctors, and nurses. It can make a world of a difference in how you chart, diagnose, code, even how you see or interpret clinical documentation. If only to sharpen your coding skills or to gain a better understanding on how accurate diagnosing could change the result of patient care, enroll in this program. There is an abundance of information that can be learned and used in your profession.

You will note an improvement in your own documentation and will want to apply your CDI knowledge because you now know the value in it. You will gain total understanding of the impact that CDI really has on health care. This program will drive you to want to better your clinical documentation—to educate your peers and share this information. Why? Because as health professionals, we took an oath and we all have the same goal: to provide the best of care to our patients.

We love hearing from our members! If you have an interesting story or experience to share, connect with us at [email protected].

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