Clinical Documentation Improvement

Salumatics® provides integrated services, solutions and healthcare expertise enabling our customers to securely access and manage the value of their information.

Get the credit you deserve

Canadian health record coders have long struggled with missing, incomplete or non-specific physician documentation, resulting in lower quality of data or many frustrating hours spent in the query process. With evolving provincial and territorial funding allocation models, such as the new Health-Based Allocation Model (HBAM) in Ontario, hospitals need to help their clinicians improve documentation practices now.

Salumatics has a team of Clinical Documentation Improvement (CDI) specialists that have been working with physicians in North America for over a decade.

An effective CDI Program can ensure physician documentation is complete and accurate, leading to:

  • assigning appropriate Case Mix Groups
  • increasing coding productivity and turnaround time
  • ensuring publicly reported outcomes accurately reflect the quality of patient care
  • accurately portraying the hospital’s severity of illness and case mix index

Reduce your risk

Accurate coding relies primarily on physician documentation. Incomplete clinical documentation wastes valuable time and resources to get charts completed, and creates the risk of underreporting resource use and case mix.

Experience has proven that effective physician education about clinical documentation requirements must be customized based on their actual clinical practice and documentation habits.

Improving data quality and documentation also leads to improved key performance quality indicators such as wait times, mortality rates and infection rates.

Unlock the value of your information

CDI isn’t just about compliance. If the patient experience is properly documented, coded and analyzed, hospitals benefit from the value of understanding their practices, patterns, interventions and outcomes. Better information leads to better decisions.

Phase 1: We conduct an initial risk assessment to determine which high volume hospital service lines have the highest potential for documentation improvement, including review of:

  • Common conditions: CHF, COPD, Pneumonia, Respiratory Failure and Urosepsis
  • Patient groups with longer than expected LOS
  • High complexity CMG with low percent of complications and comorbidities
  • Factors that impact resource weights

Phase 2: We perform in-depth audits of patient charts from a coding and documentation perspective. These audits identify opportunities for improvement:

  • Evaluate coding accuracy, compliance to coding guidelines and appropriateness of CMG assignment, and capture of hospital acquired conditions.
  • Identify physician documentation issues and improvements to existing CDI initiatives
  • Conduct a financial analysis to report on the impact on funding, based on level of specificity, capture of additional co-morbidities and conditions and factors that influence resource weight assignment.

Phase 3: We create customized education tools for physicians based on the results of the chart audit, including:

  • Training material for your in-house CDI personnel, focusing on diagnoses requiring specificity and clarification
  • Effective post-discharge query process and physician communication templates based on common documentation challenges
  • Customized workshops or presentations for physicians to provide them with requirements specific to each specialty or to their individual practice

With our experience in coding, data quality auditing, health information management and data analytics, the Clinical Documentation Improvement team at Salumatics is uniquely positioned to deliver innovative solutions to our clients.

For more information, please email sales@salumatics.com