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 the latest edition, we’re talking to Linda Dare, CDS at Latrobe Regional Health in Traralgon, Victoria. With 25 years of experience in nursing and midwifery, including leadership roles, Linda's journey into the CDS role is truly inspiring. She's brought her wealth of clinical knowledge and teaching experience to the world of documentation improvement.
Tell us about your current role
I currently work 4 days a week as a Clinical Documentation Specialist.
What is your career background, and how has that contributed to your ability to work as a CDS?
My background is nursing & midwifery. I spent the last 22 years working on a busy maternity / gynaecology ward, including 8 years as an associate unit manager of postnatal / labour wards. I also did 12 years of teaching antenatal classes.
What made you apply for a CDS role?
After being clinical for 25 years I was looking for a change. I had never heard of a CDS until the role was advertised. I looked into it and it sounded really interesting. I thought I would love the teaching aspect of the job as well. The role of the CDS ended up being so much bigger and more complex than I anticipated, yet I love it because I love the challenges that come with the role.
What does your typical day look like?
My morning usually involves discussing queries via email and printing them off for the coders (most of our coders work remotely and are from all over Australia and New Zealand). I have a very supportive coding manager who I meet with and discuss issues with on a daily basis. I then usually have appointments with doctors to have queries answered. I often do documentation improvement teaching sessions in the afternoon to the nursing staff, doctors and midwives. The last couple of hours in the day are usually spent doing retrospective audits.
What was the moment CDI really “clicked” for you?
A few months after I started in this role my manager showed me spreadsheets of the queries I was doing from audits and I could see I was making a real difference to our funding. It gave me motivation to work even harder.
How would you describe your personal CDI philosophy?
This would be to work with integrity. Being one of the only people in the hospital having an excellent knowledge of both clinical practice and how coding works, puts you in a position where people have to trust you. Coders trust my clinical knowledge and advice and the clinicians trust what I tell them how and what they need to document.
What is the biggest challenge you have faced as a CDS?
Non-compliance and non-engagement of clinicians. Despite doing teaching sessions with every new young doctor that starts here and using pneumonia specification as an example of ways they can improve their documentation, we still see so many pneumonia- unspecified, documented……it can become exasperating!
What is the most memorable “win” you’ve had?
When one of our senior consultants who is very ‘pro’ the CDS role, introduced me to his colleagues and said “oh you have to meet Linda, she helps us make money for the hospital, you need to meet with her and answer her queries whenever she asks”. Yay, finally some respect and recognition for my important role!
If you could talk to yourselves 10 years ago and tell them you’re now a CDS, what do you think they would say?
You need to apply for a job as a CDS now and not wait another 10 years!
Favourite DRG?
I like all the O01 O60 DRG’s, actually any of the obstetric ones.
Favourite additional diagnosis?
Being a midwife, I love O721 Postpartum Haemorrhage – it leads to so many other additional diagnosis codes.
What are you excited about in the future of your role?
I feel I never stop learning in this role so continue to love it and it challenges me every day. I am excited that the role is becoming more recognised in Australia and we and now getting more and more learning opportunities.
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.