Engaging at the Bedside

Chart Police“Here come the ‘chart police.’” 

Every clinical documentation specialist (CDS) has heard it. “Chart police.” For those CDSs with a nursing background, it is often heard from those nurses they have worked alongside in the following ways: 

(1) when discussing their new role

(2) while explaining their current role

(3) when attempting to recruit bedside nurses into the CDS career path. 

How do we educate our bedside-loving peers about the value that their documentation brings to the final coded record? Show them. 

Nurses love evidence.

It has been the foundation of nursing practice since Florence Nightingale demonstrated that good hygiene improved outcomes. Pull up a stand-alone encoder and show them the difference made by inclusion of wound staging or body mass index. Clinical documentation integrity is an obscure role to most nurses so take the opportunity to translate the language. Instead of demonstrating the MS-DRG, show the difference in severity of illness (SOI) and risk of mortality (ROM) when including their documentation. Interpreting SOI and ROM is a quicker soap box discussion than CC/MCC capture and translates clinically with almost no discussion. 

ICD-10-CM Guidelines for Coding and Reporting allow us “few exceptions” to the rule that “code assignment is based on the documentation by patient’s provider” but, nurses need to know that their documentation often triggers CDSs to know that a query opportunity exists. Default templates utilized by providers may repeatedly explain that the patient is oriented, but night shift nurse documentation may paint a different picture of a sundowning patient. That picture is incredibly valuable to the accuracy of the coded record, particularly when the provider is documenting in progress notes when assessing the same patient during the day. 

The remote world has done wonders for production but can put a strain on those opportunities to engage our healthcare partners and demonstrate value. Other ways to engage our nursing colleagues in understanding the value of their education: round with them during an onsite day, engage nursing management to become part of the nursing skills fairs (quality documentation is inarguably a skill), or seek out the opportunity to present to new nursing hires during orientation. 

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