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!
This week, we hear from Jeremy Jones, CDS at Gosford Private Hospital in New South Wales. Hear how observing real change in documentation practice from a clinician fuelled his motivation for CDI and his passion to provide nothing but the best delivery of care for our patients and keep our hospital sustainable.
Tell us about your current role.
Currently a Clinical Documentation Specialist for Gosford Private Hospital. A first for our organization, I have driven the CDI project for 12 months.
What is your career background, and how has that contributed to your ability to work as a CDS?
Working in Nursing for 8 years, an enrolled nurse with a background in Rehab/Medical, Orthopaedics, General Surgical, discharge planning and wound care. Additionally, having a detailed history of business management roles and regional consumer accounts experience. This has intertwined with clinical experience to provide a great platform for being a CDS.
What made you apply for a CDS role?
I always strived to undertake new clinical skills and was always on the lookout for further skills to expand my healthcare career. Documentation of the inpatient journey, patient quality and safety always interested me. So when the opportunity came up, I took it with both hands.
What does your typical day look like?
Never start a day without coffee. Maybe 2. I then fire up the laptop to check emails and load all the necessary reports to plan out my day. I highlight priority patient reviews and check any discharges. I check the theatre list to see if I can follow up any outstanding queries so can see the doctor in person or leave a written query to be answered in between cases. Depending on the day, I may join specific clinicians on rounds to see if any complexities have arisen or get queries answered if required. I will visit the health information team at some point in the morning and see if there is any feedback I can take back to the clinicians, or follow up on coding with our senior coder. Days can also include meetings, discussions with some of our quality and safety team, and conversations with clinicians.
What was the moment when CDI really “clicked” for you?
At the start, it was hard to see the outcomes or improvements in the documentation. One day, I saw change, real change. A doctor had included something in the operation report that I had queried a couple of times and we had conversations around those queries. Another doctor also started documenting the reasons for treatment and underlying causes after I presented some informed reasons in a discussion. I had breakthroughs and never looked back.
How would you describe your personal CDI philosophy?
Positivity! That conversation to a doctor, that education to staff on documentation, that email to a clinician, that meeting to committee members, make it positive! Positivity breeds understanding, encouragement and enthusiasm.
What is the biggest challenge you have faced as a CDS?
Understanding that not all clinicians are interested in documentation improvement.
What is the most memorable “win” you’ve had?
Having a major clinician understand what my role actually is and why it’s vital to the hospital and the patients. The change in sentiments to a CDS and the “door opening” to improving the documentation standards and delivery of complete and safer care of the clinician's patients.
If you could talk to yourself 10 years ago and tell them you’re now a CDS, what do you think they would say?
What’s a CDS? What’s that got to do with nursing? And have the spurs won a trophy yet?
Favourite DRG?
G02B or I09C – Generally they are complex patients and the record is always fascinating to review.
Favourite additional diagnosis?
K91.89 – adhesions due to previous surgery and D62 – acute post haemorrhagic anaemia. Both complications that are great examples to guide clinicians to improving the documentation.
What are you excited about in the future of your role?
The CDS role is such a new concept to our hospital network that is frequently evolving. With great support and a constantly changing healthcare landscape, I’m excited to lead our CDI journey into the future to deliver our documentation improvement message and outcomes. I want to provide nothing but the best delivery of care for our patients and keep our hospital sustainable.
Want to be the next CDS profiled on CDS Snapshot? Contact us at community@cdia.com.au.
We invite you to share your ideas, experiences, and achievements in CDI by submitting content to the CDIA Community! Contact community@cdia.com.au to learn more.