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 Roxanne Carroll, CDS at Gold Coast Hospital & Health Service in Queensland. Hear about Roxanne's philosophy and approach to supporting clinicians to gain a better understanding of the requirements and implications of documentation improvement.
Tell us about your current role.
By providing detailed clinical review of patient records and liaising closely with medical colleagues, I contribute to improving the integrity of information in the digital medical record, supporting safe patient care, interdisciplinary clinical communication and revenue assurance. I also provide ongoing education, support and mentoring to promote best practice in clinical documentation for medical officers, and other healthcare providers, including nursing, midwifery and allied health.
What is your career background, and how has that contributed to your ability to work as a CDS?
My background experiences and qualifications in nursing, and safety and quality improvement have been invaluable to achieving the desired outcomes in documentation improvement. As a Clinical Nurse Consultant, I have diverse experience including general medical, surgical, and emergency nursing and also Haematology / Oncology including bone marrow transplant. In these roles I have learnt the value of meaningful, effective professional relationships to achieve key deliverables. Effectively communicating, negotiating, advising, and working collaboratively with team members is crucial to success. From my roles in quality improvement projects and patient safety reviews, establishing an evidence base based on sound methodology is invaluable for progressing practice change.
As the Quality Improvement Lead for Clinical Handover and having completed my thesis on Nursing Handover practice, I have a comprehensive understanding of the importance of communication and enablers and barriers to change that has been transferrable to promoting practice change in clinical documentation.
What made you apply for a CDS role?
As someone with a keen eye for detail, who really enjoys reading the story of people’s lives – this was the job for me!
What does your typical day look like?
My typical day involves doing a virtual ‘ward round’ with several clinical services and generating ‘live’ documentation queries. I also perform analysis of previous months' documentation queries to determine the value realised, emerging trends, and to be able to provide feedback to the clinical services to drive further improvements. Some of my day will be spent in the planning and preparing of educational material for the medical officers, and liaising with many colleagues; Health Information Leads, Clinical Coders, Clinicians, and of course my great CDS team members.
What was the moment when CDI really “clicked” for you?
I have many of these moments! It’s very professionally satisfying when a documentation query results in the complete and accurate capture of clinical complexity for the patient.
How would you describe your personal CDI philosophy?
My philosophy to CDI work is the same philosophy I have brought to my other quality improvement projects; to listen and understand the people you are asking something of, and to have the patience to walk people step-wise through the transition of change. It’s a journey of learning, for myself as much as the people I work with.
What is the biggest challenge you have faced as a CDS?
I have a saying: “it's very difficult to ask people to ‘fix’ something when they don’t perceive it as ‘broken’.” This is very true of documentation practice, so the biggest challenge is supporting clinicians to gain a better understanding of the requirements and implications of documentation improvement.
What is the most memorable “win” you’ve had?
The most memorable win is after engaging and supporting a clinician to increase their understanding of CDI and the purpose and outcomes associated, then having the clinician be a visible and vocal advocate for CDI within their peer networks. Facilitating learning and professional growth is the real measure of success.
If you could talk to yourself 10 years ago and tell them you’re now a CDS, what do you think they would say?
Communication has been central to many of my previous roles, so even 10 years ago I would not have been surprised to be told there will be a need in the future for continuous documentation review, education programs and improvement processes.
Favourite DRG?
F14 – Vascular Intervention, except Major Reconstruction, without CPB pump. Patients who require vascular services are frequently clinically complex, with many co-morbid conditions to manage. I really enjoy reviewing this cohort and supporting the capture of the complex care that this service provides.
Favourite additional diagnosis?
G54.6 Phantom limb syndrome with pain and G54.7 Phantom limb syndrome without pain. This additional diagnosis is great to capture as in my experience it is rarely well documented, although from a clinical perspective I can see the teams' great efforts in providing additional care for this condition.
What are you excited about in the future of your role?
I am very excited to see the growth in this area of healthcare improvement, and I project that CDI will be even more vital as so much of healthcare transitions to virtual and / or remote care. I’m really grateful to have the opportunity to be involved in the development and establishment of a CDI service.
Want to be the next CDS profiled on CDS Snapshot? Contact us at community@cdia.com.au.
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