by Basanti Sharon Olsen RN, MSN, CCDS
Does the term “CDIS” make you ask “What is that?” or maybe even trigger a reference to a forensic based television show? Well, considering the definition of forensic to mean “legal evidence”, the triggered reference is not too off base. CDIS stands for Clinical Documentation Improvement Specialist – any yes – in reality we do perform a forensic analysis on the active open medical record.
In addition to contributing to the shared goals of our Case Management Department and collaborating with the talent and expertise of our Social Workers, Nurse Case Managers and Utilization Review partners, the strongest focus of the CDIS is to facilitate documentation in the medical record that expresses accurate severity of illness.
CDIS forensic analysis endeavors to capture documentation that reflects the level of Physician expertise used to care for our Patients. In addition to Consultants, Physician expertise entails utilization of a spectrum of hospital service lines including but not limited to: Case Management, Nursing, Pharmacy, Physical Therapy, Nutrition and many other disciplines. Physician documentation of accurate and specific diagnoses treated captures severity of illness and intensity of service thereby reflecting resources utilized to provide optimal care.
The medical record is a resilient reflection of resource consumption based on the degree of diagnosis specificity. Clinical Documentation Improvement Specialists utilize their skill sets to query the Physician as needed by requesting clarification of acuity, severity and specificity of conditions treated.
The forensic component of the CDIS role is best expressed in our process of medical record analysis that results in a credible evidence based Physician query. CDIS analysis include:
- ascertaining relevance of documented signs and symptoms
- surmise role of active and inactive co-morbidities
- assess caliber of treatment given
- review severity and specificity of documentation
- incorporate Coding Guidelines and ethics to identify the chief condition that occasioned the hospitalization.
Consider once again, the definition of forensic to mean “legal evidence”, and that the medical record is a timeless reflection of an episode of care, you may appreciate the role of the CDIS to facilitate and maintain the integrity of timeless evidence found in the medical record.
