Case Study: Ancillary Clinicians Can Play a Key Role in Clinical Documentation

The nutritionists at a 350-bed teaching hospital in the Southwest were very interested in participating in the clinical documentation program that was just being launched at the hospital. Maryanne, the director of the nutrition department, had previously worked at a regional academic medical center that had implemented a clinical documentation program with which she was involved. The medical center was sure that Maryanne’s staff could make an impact on the physicians. They decided to have Maryanne’s staff trained in the basics of clinical documentation and for them to communicate, when necessary, with the clinical documentation specialists.

The first step of the program would generally involve formal training sessions with the entire staff in the nutrition department. In this case, however, the hospital decided that it made sense to train Maryanne first since she was such a strong proponent of the process. By training Maryanne, it would allow her to obtain more knowledge about the program and the responsibilities of her team. It would also allow her to make a better determination about the level of involvement she was willing to commit her staff to regarding the program. Finally, by having Maryanne learn the process first, she could become part of the instructional team that trained her staff. From a CAMP Method perspective, this is the best approach to take for optimal and sustainable learning.

Maryanne was trained by the hospital’s physician leader and the clinical documentation manager. She even spent time on the units reviewing records in addition to her classroom training. As she was learning, Maryanne spoke about the experience to her staff in a positive way, and she was excited to have them trained as well. When it came time to do the staff training, the physician–clinical documentation manager team led most of the training, but there were several components that Maryanne was asked to present. In addition, she commented often to the group about her experiences reviewing documentation on the units. Because of the nutrition staff’s expertise, the case examples that involved nutrition or metabolic disorders were focused on during the training. The entire nutrition department was very excited about getting started. By the end of their training session, they decided, along with the clinical documentation team, that the nutritionists would have a specific role in documenting clearly in their progress notes or reports whenever a patient met the clinical criteria for malnutrition, obesity, morbid obesity, and similar disorders. The clinical documentation specialists would then be able to generate queries. The nutritionists even designed their own pocket card to refer to and give out to physicians.

This team effort was successful for the organization and produced improved documentation almost immediately in nutritional and metabolic disorders. The process was sustained because the group used the CAMP Method for training, which encouraged a strong sense of self-efficacy. It was important that the director of the department was groomed to participate in the peer learning aspect of the training process. It was also important that the nutrition staff members were able to express their concerns about the role they were going to play and that they had input into what their role would look like. This correlated with the asking and coaching aspects of the CAMP methodology.

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