Transcript 280204
The Art of Communication in CDI and Beyond Colleen Stukenberg, MSN, RN, CCDS, CMSRN Clinical Documentation Management Professional FHN Memorial Hospital Freeport, IL Communication • “A process by which information is exchanged between individuals through a common system of symbols, signs, or behavior” (Merriam Webster, 2012) • 256,000,000 Google hits What’s the Issue? • Multiple modes of communication – Verbal – Body language – Tone – Written – Visual Communication Styles Aggressiveness • • • • • • • Shouting Pointing Loud Yelling Brazen Forceful CAP LOCKS!!! Passiveness • Avoidance Passive-Aggressive • Sneaky • Dangerous Assertive • Positive • Confident • Ownership Role Model • What does this person look like? – Open – Friendly – Positive – But remember … • Looks are not everything Importance of Trust • Knowledge • Accuracy • Follow-through Scenario #1 • 12/18 a 78 y/o female admitted with cellulitis, systolic CHF, and UTI. The pt has +1 edema of BLE and red, warm-to-touch RLE with 2-inch ulcer. O2 at 2L/min per nc. UA WBC, (+) nitrites, bacteria, urine culture pending. • 12/8 CXR – Kerly lines, cardiomegaly, vascular congestion, pulmonary edema. • Pt is on po furosemide, carvedilol, IV antibiotics, and dressing to RLE. • Query written for severity of CHF with the positive CXR, meds for CHF and oxygen. Scenario #2 • 72 y/o male admitted with fever, dyspnea, dehydration • Temp 103.2, WBC 18K, bandemia, blood culture pending, CXR: neg for infiltrate, lactic acid 3.1, BUN 41, creat 1.27, productive cough, lung sounds rhonchi • Query for sepsis regarding the fever, WBC, and bandemia Scenario #3 • Pt chart coded as DRG 194 Simple pneumonia with CC. • Doctor says this patient was a lot sicker than this. Sputum culture MRSA, UTI, and was in ICU for respiratory distress with this his CHF. Why was the DRG only a simple pneumonia? • “I am sure I documented everything.” • You look at the chart. – Pneumonia, UTI, acute CHF – Queried for the type of pneumonia and CHF Assessing the Situation Observer Sender Receiver What Is Emotional Maturity? • UGH! NOT AGAIN! • BLAH! BLAH! BLAH! Perspectives • Activity • What do you see? • First thing that comes to mind Different Perspectives • Who’s right? Who’s wrong? • Can they both be right? • How do we think? Scenario #4 • 67 y/o female admitted with exac CHF, ulcer to • • • • • RLE with cellulitis, COPD, diabetes BGM 327, O2 sat 87% on RA, dressing to RLE, Wound culture: Staph sensitivity pending IV Vanco, nebs, O2, IV furosemide, IV steroids, surgical consult for wound, telemetry: NSR to ST, SS insulin Current LOS 6 days 3rd time admitted with CHF in 2 months Different Roles/Different Perspectives • • • • • • • Physician Nurse CDI Coder Case manager Administration Patient Working Together • • • • Common goals Committees Projects Barriers? Improving Content • • • • Knowledge Accuracy Organize your thoughts Templates • • • • • • Who’s your audience? What’s your purpose? Bullet points Concise Clear Positive So What’s the Confusion? • Order written at 1800 – Furosemide 40 mg po every day – Has med, dose, route, frequency Still Not Getting the Message? • • • • Processes Procedures People Places Other Pointers • • • • • • Last word Respect Flexible Humor Timing The big picture Examples We Have Experienced? • • • • • • Mad about queries All about money Ignore queries Schmoozer Just want to take care of patients Administration again Is This the Right Person? References • Merriam Webster. Retrieved January 7, 2012, from www.merriamwebster.com/dictionary/communication • Stukenberg, Colleen (2010). Successful Collaboration in Healthcare: A Guide for Physicians, Nurses and Clinical Documentation Specialists. Productivity Press, Taylor & Francis Group, New York, NY. Questions? In order to receive your continuing education certificate for this program, you must complete the online evaluation which can be found in the continuing education section at the front of the workbook.