Let Doctors Be Doctors

By Jennifer Woodworth, Director, Clinical Documentation Integrity Program, Swedish Health Services

Physicians don't always realize the correlation between their clinical documentation and the level of credit they get for providing quality patient care.

No one chooses to work in the healthcare industry because it’s easy.  We do it because we want to help others.  The mounting frustrations doctors face as the result of an increasingly burdensome healthcare system are not only understandable, they are justifiable.  These men and women did not go to medical school to sit through hours of meetings about code sets.  Their primary responsibility is to treat patients.  And for those of us who work with them, it is our role to be the trusted partner of our doctors and clinical care teams—to ensure they share the right information where and when it’s needed. I’ve spent close to a decade working with physicians on clinical documentation to make sure it reflects their intent and they get credit for the level of care they are providing.

Over the years, the doctors have taught me some valuable lessons.  When it comes to implementing a successful clinical documentation improvement (CDI) program, start with these three fundamentals...

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