Massena Memorial Hospital using new documentation program as part of efforts to keep bankruptcy at bay
MASSENA -- Massena Memorial Hospital has undertaken a new program as a measure to counteract billing issues that contributed to the institution nearly going bankrupt.
With all the changes in healthcare and the differences in payment structures, the focus of Clinical Documentation Improvement is on quality records-keeping, which affects not only the inpatient setting but outpatient as well.Expanding CDI into different areas of MMH represents efforts to have a more global view of patient populations and complete and accurate documentation of the clinical picture, according to MMH public relations director Tina Corcoran.
CDI specialists review patient medical records and assess whether all conditions and treatments are documented.
This documentation paints an accurate picture of the severity of a patient’s illnesses and risk of mortality.
When the documentation is unclear or deficient, CDI specialists prompt (also known as “query”) physicians to provide clarification.
The specialists serve as the bridge between health information management and clinical staff. They comply with Medicare or private payer rules and regulations, Corcoran said.
The program uses Clinical Documentation Specialist Marlyn Berry's extensive medical background, from her 12 years in medical surgical, along with time in the emergency room, intensive care unit, operating room and endoscopy to her time as a nursing director, Corcoran said.
Her experience plus her training as a CDI specialist and the use of 14,567 diagnoses codes and 3,882 procedure codes "paint an accurate picture of the severity of a patients illness and risk of mortality ... serving as a bridge between health information management and clinical staff," according to Corcoran
"Documenting patient care delivery is an integral part of what our caring medical staff, nurses and allied health professionals do every day. CDI complements the excellent care patients receive as at MMH by insuring an accurate and complete medical record," said Corporate Compliance Officer, Julie Zyzik.
"I think the CDI program has been a very educational program guiding us into the nuances of documentation and starting the CDI program shows how well all of us at Massena Memorial Hospital worked as a team," said John Burnett, chief of medicine.
Berry collaborates with other professionals in our hospital clarifying records to capture the severity of a patient’s illness.
"Success of our program is based on our collaboration," Berry said.