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!
We're staying in Sydney to talk to CDIA's own Samantha Ryan! Sam's passionate belief in the power of CDI, and her love of educating both clinicians and CDSs, is absolutely inspiring.
Tell us about your current role.
I work with the amazing team here at CDIA as a Clinical Documentation Nurse Consultant. This basically means that I get to meet with some brilliant CDSs! I am involved in conducting training and education sessions with clinical staff. The part of my role that I love the most is the coaching that occurs in the early part of the CDS’s new role. There is so much excitement combined with apprehension, and I absolutely love observing the change that occurs when the CDS gains confidence in their role and they find their groove.
What is your career background, and how has that contributed to your ability to work as a CDS?
When I was really young, I always wanted to be a teacher. I used to sit my little brother down in front of a chalk board and do spelling and reading with him all the time, the poor thing (funny that he doesn’t remember it as fondly as I do!). I changed my mind about teaching but it’s interesting that my nursing career pathway included teaching when I practiced as a clinical nurse educator. In my degree also, I specialised in clinical nursing and teaching, I think it might be in my blood. Imparting knowledge to others has always been important to me, and I always loved working with students and graduate nurses and watching them grow.
What made you apply for a CDS role?
A number of things contributed to my application for the role. I had spent the majority of my nursing career working in acute care settings, looking after some hugely complex patients. I enjoyed the challenge that this complexity brought about yet often found myself perplexed by the accompanying documentation. It was at times ambiguous, sometimes outstanding, other times completely absent, but most of the time it was plain inconsistent. I could see that there was a fantastic opportunity, not only for me to understand more about the classification component of healthcare, and its impact on data integrity and funding, but more importantly I saw it as an opportunity to facilitate increasing transparency in the medical record. I know that this is part of our CDIA values, but I one hundred percent believe that by increasing that transparency in the record, we are promoting the delivery of safe care to every patient because everybody knows what’s going on, and that was my main motivation for applying for the role.
What does your typical day look like?
Those that know me well will not be surprised when I say that my day always starts with coffee! Seriously though, my day can consist of many different activities. Coaching sessions might be with a CDS or team of CDSs that have just started their journey or with an established team that are looking to develop specific elements of their program. I am often involved in CDI audits which I enjoy as I get to experience an organisation's clinical documentation first hand and can contribute to meaningful feedback for the site. Rolling out CDI programs is another big component of my role, working closely with the sites to plan training, clinician education and immersion. Immersion is a brilliant opportunity to work with a CDS in real time and observe the processes that they have in place within their program. I am often involved in training those that are working either as a CDS or as part of a CDI team, I love this part of my job too as I get to meet and interact with all sorts of interesting people from many different walks of life. I love hearing their stories of how they got into CDI and generally sharing my passion for this niche space. In short, my typical day is varied.
What was the moment when CDI really “clicked” for you?
I think that when I was looking to apply for my CDS role, I had many conversations around CDI and had a realisation that I had been practicing for all of my nursing career unaware of the impact that my notes had on a more macro level. I realised from these conversations that my notes were read by others, not just my colleagues, but clinical coders. From that I understood the importance of accurate documentation for meaningful data and that link to reimbursement. As a clinician the data integrity component of CDI meant more to me as it reflected the complexity of the patients that I cared for on a day-to-day basis. If somebody then tells you that ‘hey, the patients that you care for do not look that complex on paper” you kind of feel wronged. That was when I suddenly thought ‘a-ha, that’s what needs to happen’.
How would you describe your personal CDI philosophy?
“Keep it real”. Often clinicians are under a huge amount of pressure and CDI can come across as a little insignificant in comparison to the delivery of patient care. My philosophy is to work with clinicians collaboratively as opposed to enforcing CDI onto them. My mantra is, CDI is here to stay, how can I help you within this space? That may be in relation to querying, education and by developing meaningful working relationships with clinicians, to ensure that the clinical truth is captured in the record at all times.
What is the biggest challenge you have faced as a CDS?
I think that forging trusting relationships with clinicians is a challenge, particularly as there is a lot of scepticism around CDI and developing that relationship is essential for great outcomes within programs.
What is the most memorable “win” you’ve had?
As a CDS, there is nothing more rewarding than being contacted by a clinician, whether it be a nurse, doctor or an allied health worker, to let you know they have documented ‘due to’ in their patients’ record. As a CDI consultant my wins occur frequently when new CDSs come into their own within their program and then I get to enjoy their ‘wins’ with them. It’s like the gift that keeps on giving.
If you could talk to yourself 10 years ago and tell them you’re now a CDS, what do you think they would say?
Really?! When can I start??
Favourite DRG?
Of course I don’t just have one, I have two. Instantly I gravitate towards G02 and F08, they are both meaningful to me as they were the first DRGs that I worked with. If I am totally honest though, I don’t have favourite DRGs, rather I have favourite MDCs. MDC 5 & 6 always pique my interest as my background is in Vascular and GI nursing. I love these specialties as they both provide a great opportunity to have meaningful conversations with clinical staff around the complexities often found within these cohorts of patients.
Favourite additional diagnosis?
Oh, there are so so many. I think that K91.89 in capturing that during abdominal surgery, adhesions were due to previous surgery. It was the first query that I made to a surgeon, and it made perfect sense that by documenting this demonstrates the complexity of the patient, considering that adhesiolysis can be time consuming and might mean the difference between a laparoscopic and an open procedure.
What are you excited about in the future of your role?
I love to see how the CDI space is evolving. There is now CDS Certification available, and the CDIA Community provides an excellent opportunity to virtually hang out with others that work within CDI or have an active interest in it. I am super excited about the CDI conference that is planned for September this year. Last year’s conference was such a wonderful opportunity to get together and hear from experts and those that are involved in new and established programs. For me personally, I get to continue working with you all at CDIA and I am particularly looking forward to some more face to face interactions through training and immersion.
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.