The ending of 2009 gives us an opportunity to reflect upon some of the changes that occurred last year within our association and the newly developed PHIMA Clinical Documentation Improvement Program track. Since CDIP alignment with PHIMA in the fall of 2009 we have been able to provide two Clinical Documentation Improvement symposiums. One was held on August 6th at Abington Memorial Hospital and our 2nd symposium was held on November 2nd at The Reading Hospital and Medical Center. Both symposiums were well attended. The speakers were knowledgeable and presented material highly relevant to Clinical Documentation Improvement programs. Topics ranged from the following: The Role of the Physician Champion, Performance Outcomes and the CDI Program, Final Rule for ICD9CM October 2010 Updates, Identifying Infections in the Medical Record: POA vs. HAC, Identification of Nutritional Issues in the Medical Record, Pneumonia/COPD documentation and Core Measures, Dementia and Delirium diagnoses and specificity for coding and documentation, Renal Disease principal diagnosis/documentation/coding and BMI documentation for CC capture of Obesity and Malnutrition codes.

Looking forward in 2010 will find your CDIP committee working toward planning future symposiums before the completion of the fiscal year. An outcome from one of our PHIMA executive meetings was the suggestion to make the CDIP symposiums more geographically available throughout the state. Based on the committee’s discussion and following approval we will be providing our next CDIP symposium in western PA at St. Clair Hospital in Pittsburgh on March 25, 2010. A variety of topics of interest to everyone involved in a Clinical Documentation program and coding will be offered.

The Clinical Documentation Improvement Program also plans to provide several webinars during the remainder of fiscal year 2010 to facilitate education at the convenience of your own facility and for the very first time CDIP specific education will be provided at our Annual PHIMA meeting in May, 2010.

To stay informed of all CDIP events with PHIMA, please keep checking the PHIMA web site for further notification of future educational opportunities throughout the year and hopefully at a location near you.

Formally submitted,

Clinical Documentation Improvement Specialists Co-chairs: Paula M. Frost, RN, CTR and Michele Johnson, RN, BSN

(The CDIP executive committee members include Paula Frost, Michele Johnson, Terry Backowicz, Stephen Bradley, Chris Garey, Lori Lafaver, Vicki Marth, and honorary member, Brittany Bianco representing the PHIMA student extern from the University of Pittsburgh. The co-chairs are Paula Frost RN, CTR Reading Hospital and Medical Center and Michele Johnson RN,BSN Wellspan Health.)