Clinical Documentation Director

Clinical documentation professionals are a necessary conduit for the initial and continued success of an organization’s clinical documentation program. Because they spend a significant amount of time interacting with physicians during both the training and the review process, it is important to ensure the documentation professionals themselves are trained in how to interact with physicians. CDPs should be trained in approach and content regarding their communications with physicians to ensure a compliant and effective program. The book describes the ideal background of clinical documentation professionals as well as training topics to ensure an effective and compliant program.

Clinical documentation professionals (CDPs) are usually clinicians who have been trained in correct clinical documentation practices. These clinical documentation professionals are the operational center of the program. They are charged with coordinating training and education activities. In addition, they are charged with the program’s concurrent review process, which involves reviewing clinical documentation as close in time as possible to the initial documentation to identify any documentation that does not meet the established criteria for high quality clinical documentation. Ideally, as physicians are empowered with initial and then continuous follow up training, the amount of concurrent review necessary should decline because quality is improving. In reality, most organizations unable to set aside internal resources and/or obtain cooperation from physicians to attend the initial and follow up training (as described in this book) necessary to produce the increase in quality without concurrent intervention from CDPs.

As a way to assess the CDP-physician relationship, Volume 2 contains an assessment survey to be completed by all CPDs and if possible, some sampling of members of the medical staff. The survey for the CDP team asks questions about the respondents’

• Knowledge of physicians as a group
• Knowledge of each physician/individual physicians
• Formal communications
• Informal communications
• Hospital’s “culture clarity”
• Physician support for hospital activities
• “Serving your physicians”
• Level of respect (that physicians have for the CDP staff)

The book addresses the assessment process and steps you can take to identify specific issues and make improvements in the CDP-medical staff relationship.