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 time, we're talking to CDIA's own Nour Alatari. With her strong clinical and safety and quality background, Nour uses her experience and skills to mentor CDSs just beginning their CDI journey. But how did Nour get into the CDI space herself? Read on to find out!
Tell us about your current role
I work as a Clinical Documentation Nurse Consultant with the amazing team at CDIA. This gives me the opportunity to meet and train new CDSs from different states and different backgrounds as well as CDSs from KSA. The part of my role that I love the most is providing training where I feel I’m sharing my knowledge and experience with others and helping the new CDSs establish their CDI program.
What is your career background, and how has that contributed to your ability to work as a CDS?
I hold a Bachelor’s degree in Nursing and have experience in both adult and neonatal intensive care units. After working for a few years as a nurse I grew a passion for quality and safety in healthcare. This was the driver to complete a master’s degree in Nursing Services Administration. After that, I worked in different roles in quality and patient safety.
What made you apply for a CDS role?
I came across the CDS role job ad back in 2018 when I was working in clinical governance, and back then I had never heard of a CDS before! But when I looked at the job description it ticked all my boxes; the job was about record reviews, clinician engagement and education, safety and quality improvement, and data analysis. The only thing that I had no knowledge of was Activity Based Funding, but I was happy to learn something new.
What does your typical day look like?
There is no such thing as a typical day in what I do! It is like a smorgasbord; there is something new every day. And this is something I really enjoy: “no routine”! One day I will be working from my computer doing audits, another I will be delivering training, or having coach sessions with the CDSs. Every project is unique and every CDS we train is unique too. But the aim is always the same, which is rolling out a successful CDI program and supporting the CDSs in their journey.
What was the moment CDI really “clicked” for you?
Before I started the CDI role, I had the perception that when I was practicing as a nurse, my documentation in the record was perfect! Lol. Then the CDI role was an eye opener! It was like wearing a different set of glasses. I realised how important it is to document the indication of any treatment or service delivery, not only to capture complexities but also for a better communication between clinicians. And now I wish I had the CDI knowledge when I was practicing as a nurse, from a patient safety point of view, I would be asking myself every single step taken in patient care “why” my patient needs this treatment and making sure it is documented.
How would you describe your personal CDI philosophy?
Take it one step at a time. Usually when new CDSs start their role, it can be very overwhelming with all the new knowledge, and I always get asked this question: “where do I start?” I always say start with your strength and what you are good at and build on it! If I could do it, you could too.
What is the biggest challenge you have faced as a CDS?
My biggest challenge when I was working as CDS in a hospital, was overcoming resistance from clinicians. Sometimes it can be difficult to influence others unless you have authority to do so. And to drive change without risking the trust relationship with clinicians can be tricky. I have learnt from my experience as a quality manager several techniques. But the most important is to “let go” when it is the most appropriate thing to do.
What is the most memorable “win” you’ve had?
The most rewarding experience for me as a CDS was when clinicians asked me to round with them. Firstly, I got to learn a lot from them and secondly, I was able to influence their documentation on the spot and give tips as well. Now as a Clinical Documentation Nurse Consultant I find it very rewarding when the CDI projects are successful and the CDSs are enjoying their role and kicking goals.
If you could talk to yourselves 10 years ago and tell them you’re now a CDS, what do you think they would say?
Oh yaaaay! I can imagine myself doing my special “happy dance!”
Favourite DRG?
Although I don’t have a favourite DRG, my specialties when I was a CDS were gastroenterology, oncology, haematology, and special care nursing so all DRGs that fall under these specialties have a special place in my heart.
Favourite additional diagnosis?
Funnily enough, my first answered query was constipation (K590)! I still have a photo of me holding that answered query. I’m not sure that’s my favourite though! I like Delirium (F059) as an additional diagnosis. I believe it is one of the most poorly documented. You will see confusion documented in the record but not the word delirium. Guilty of that myself!
What are excited about in the future of your role?
Being in the field for almost 5 years now, the CDI space has grown massively. Now we have the CDS Certification, the CDIA Community, and we also held two CDI dedicated conferences in the last two years. And now that we are done with lockdowns, I am so looking forward to more site visits and face-to-face interactions with both the CDSs and with clinicians during hospital wide clinician education. I am also excited to start projects in KSA as I see a bright future for CDI in the area.
Want to be the next CDS profiled on CDS Snapshot? Contact us at community@cdia.com.au.
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