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 Melissa Browning, CDS for Mount Private Hospital in Western Australia. Hear about Melissa's journey and the impact she has made on the documentation at Mount Private Hospital due to her friendly and professional approach.
Tell us about your current role
I am the Clinical Documentation Specialist at Mount Hospital. I work part time and pick up casual RN shifts on the surgical ward.
What is your career background, and how has that contributed to your ability to work as a CDS?
I have been a registered nurse for 10 years. I have worked in many roles including; clinical nursing, nurse educator and Nurse Unit Manager. I have specialised in surgical nursing with a particular interest in orthopaedics and neurosurgery.
What made you apply for a CDS role?
I first applied for the role because I wanted a change and a chance to develop my leadership skills. After three years I left the role to again development my leadership skills as a Nurse Unit Manager. After starting a family I decided I wanted to return to the CDS role as it has the best work life balance. I have now been back in the CDS role for 8 months and I’m loving it.
What does your typical day look like?
Reviewing patient notes, speaking to the healthcare team (nurses, doctors, allied health), sending queries, providing education, attending committee meetings, and tea… lots of cups of tea.
What was the moment CDI really “clicked” for you?
After a year in the role I participated in the annual documentation audit and I could see all my hard work and effort paying off, the documentation had improved! It wasn’t just about improving hospital revenue, I could see how quality documentation was helping everyone.
How would you describe your personal CDI philosophy?
I think my friendly and professional approach is essential. I have never had a clinician refuse to complete a query.
What is the biggest challenge you have faced as a CDS?
Health funds 😂😂.
What is the most memorable “win” you’ve had?
I had many coders complaining about a particular surgeon not completing the principal diagnosis on the operation record. They said it had been going on for years and they would have to send a large amount of queries. I set up one face to face meeting with this surgeon. The surgeon had no idea what impact his writing had on the coders. There was an overnight improvement post our meeting. Now the surgeon always put a principal diagnosis and was very happy not to receive so many queries. Everyone was happy, we had great clinical documentation and all it took was a 15 minute conversation.
If you could talk to yourselves 10 years ago and tell them you’re now a CDS, what do you think they would say?
Wow sounds so exciting!
(10 years ago I didn’t even know where the medical record went after discharge!).
Favourite DRG?
F06/F04
I had never worked in cardiothoracics before my CDS role. I have learnt so much and think it’s just amazing what the surgeons can do.
Favourite additional diagnosis?
E611 Iron Deficiency
I love finding a sneaky Ferrinject on the medication chart or fluid chart!
What are you excited about in the future of your role?
The continuous learning. There’s always something new to focus on. I would love to be able to teach others to become a CDS.
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.