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 Lara Breniser, CDS for the Southern NSW Local Health District. With a clinical, research, and clinical coding background, Lara is able to effectively educate and engage clinicians to improve documentation culture at Southern NSW LHD. Here is Lara's story.....
Tell us about your current role
Currently, I am working on retrospective review projects for this financial year. We have found opportunities to optimise CDI and coding opportunities in various specialties.
I also hold regular education sessions across the district. In addition to these sessions, I have created CDI resources to highlight regularly missed diagnoses, specifics needed for various diagnoses related to their specialty, and what not to document to help clinicians know what to document when they are unsure.
I have also presented at various forums, orientations, workshops, and meetings to share CDI across the district to as many departments as I can.
In our LHD, I have also helped to establish the CDI Program as well as supported other CDSs in harnessing their CDI skills.
What is your career background, and how has that contributed to your ability to work as a CDS?
I have a background in nursing and biomedical research studies, and clinical coding. I have found that having a more comprehensive knowledge of how coding and clinical documentation work together, along with speaking coding and clinical languages, has allowed me to be successful in my current role. I am able to engage with clinicians on a clinical level, but I am also able to communicate in a way so they understand what clinical coders need from them to do their job well. My goal every day is to ensure that I am bridging the gap between clinicians and clinical coders as best I can.
What made you apply for a CDS role?
I trialled this role when I worked in Sydney as a clinical coder before COVID-19, and I really loved it. Once COVID-19 happened, I was sent to work from home, and I told myself if this role ever came available I would apply—and that is exactly what I did!
What does your typical day look like?
Currently, I am working on retrospective review projects. My time is spent reviewing records looking for potential CDI and coding opportunities, which are followed-up on by myself or my counterpart, a Clinical Coder Educator/Auditor. I also make a note to give encouraging feedback to clinicians - thanking them for their amazing documentation.
What was the moment CDI really “clicked” for you?
It happened when I was a clinical coder. I was asking why we weren’t querying diagnoses that were being alluded to through documentation of less specific diagnoses, symptoms, and results. My educator spoke with the clinician on my behalf and the clinician confirmed my diagnosis in question. A week later I was talking to clinicians at handovers and doing ward rounds to help ensure the specific diagnoses and necessary documentation was being recorded.
How would you describe your personal CDI philosophy?
I always give everyone the benefit of the doubt and believe that CDI is something everyone can do. I treat each record as detective work - what diagnoses can I find? Does everything make sense? Where are the gaps? When I can’t answer these questions, I go find the clinician that can.
What is the biggest challenge you have faced as a CDS?
Not being able to be apart of every project relating to CDI. I love my job and am passionate about seeing the positive outcomes from CDI. Learning to say “no” has been difficult, but I know I cannot effectively do my job well if I overstretch myself.
What is the most memorable “win” you’ve had?
I have two that are related. The first was when clinicians told me they were telling others about the education I had given them on CDI and that they were sharing CDI resources with each other. The second was when I was asked to present on a project I had proposed when I first started at our Leadership Forum, which has had amazing outcomes so far and we are excited to see the impact it has on how documentation is done in that specialty.
If you could talk to yourselves 10 years ago and tell them you’re now a CDS, what do you think they would say?
What’s a CDS?
Favourite DRG?
O60A
Favourite additional diagnosis?
W610
What are you excited about in the future of your role?
To see the growth of CDI across our district. For CDI to be a normal, expected practice. But, I think the most exciting thing for me would be to see different specialties have better data to use to further their skills, resources, and staffing and patients to continually have improved outcomes due to better documentation practices.
Want to be the next CDS profiled on CDS Snapshot? Contact us at community@cdia.com.au.
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