Nurses are Vital to Improving Clinical Integrity and Documentation in Hospitals

Background Nurses play a vital role as clinical documentation improvement (CDI) specialists to facilitate the coordination of patient care by providing a concurrent review of medical records for every hospitalized patient. They serve as liaisons between physicians and medical coders to ensure accurate coding, improve reimbursements, patient safety and outcomes. CDI specialist may provide support to a more transparent healthcare team by making recommendations for care based upon patient findings after thorough investigation of all laboratory and diagnostic tests along with the physicians' narrative. Method: This paper used two case studies to describe the role of a nurse CDI specialist in a hospital setting. Information from the case studies were used to show the importance of a collaboration between a nurse CDI specialist and physician to improve patient care and provide accurate coding. Discussion/Conclusion: CDI specialist provide additional oversight to help prevent billing and coding mistakes that may lead to federal investigations and or poor patient outcomes. Nurses may be optimal CDI specialists because their education and clinical experience helps them evaluate many aspects of the medical record to make recommendations for care based upon best evidence-based practice. They are able to understand the patients diagnoses and ensure that the patient's course of hospitalization is aligned with accurate treatment. Thus, providing a bridge between clinical coders and physicians by interpreting and coding narrative data concurrently so reimbursements are accurate when completed post discharge.