The Clinical Documentation Programme was implemented in Jan 2021 at Te Toka Tumai-Auckland.
There are two main workstreams; education and concurrent record review. Essentially the programme’s objective is to optimise the quality of the health information available in the health record. Clinical coders turn health information is to data, which controbutes to around 30% of the health data generated in Aotearoa.
In other parts of the world, and in some areas of NZ, CDI is used as a primary means of ensuring the healthcare providers receive the funding appropriate to the resources used. However, we have proudly led our programme with a consumer-focus and our reporting line is within Quality.
Done well, a CDI-approach to clinical documentation has the potential to change documentation culture. There are many other opportunities where a CDI-approach could be used to improve consumer experience, as well as the well known areas of patient safety and data integrity.
We currently operate at Auckland City Hospital, but Middlemore’s Surgical directorate also employees a CDS.
As author and co-creator, my vision is to see the programme adopted by every hospital in Aotearoa.