Clinical Documentation Excellence Department
Q: What is CDE anyway?
A: CDE is a process used by hospitals that employ specialists who review clinical documents for gaps in documentation and provide feedback to physicians. It is a method of obtaining complete, accurate and compliant documentation.
Q: Why can’t you just tell me what to write in my note?
A: Just as an attorney cannot “lead” a witness into a statement, CDE nurses cannot lead physicians in their documentation. A physician may be contacted by a CDE RN during rounds or by a query (communication tool in I-Connect used to clarify documentation) in order to clarify documentation.
Q: So…What’s the point?
A: The primary purpose of accurate, specific and complete health record documentation is continuity of patient care. This serves as a means of communication among healthcare providers. It is also used to evaluate the adequacy and appropriateness of quality care, provide clinical data for research and education and support reimbursement, medical necessity, quality of care measures and public reporting of services rendered by a healthcare entity.
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A: CDE is a process used by hospitals that employ specialists who review clinical documents for gaps in documentation and provide feedback to physicians. It is a method of obtaining complete, accurate and compliant documentation.
Q: Why can’t you just tell me what to write in my note?
A: Just as an attorney cannot “lead” a witness into a statement, CDE nurses cannot lead physicians in their documentation. A physician may be contacted by a CDE RN during rounds or by a query (communication tool in I-Connect used to clarify documentation) in order to clarify documentation.
Q: So…What’s the point?
A: The primary purpose of accurate, specific and complete health record documentation is continuity of patient care. This serves as a means of communication among healthcare providers. It is also used to evaluate the adequacy and appropriateness of quality care, provide clinical data for research and education and support reimbursement, medical necessity, quality of care measures and public reporting of services rendered by a healthcare entity.
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In cancer's aftermath, helping survivors confront "late effects"
Even after cancer is defeated, it can cast a lifelong shadow. “Cancer survivorship represents a very critical phase,” said Smita Bhatia, M.D., M.P.H., a pediatric oncologist and director of the new Institute for Cancer Outcomes and Survivorship in the UAB School of Medicine and associate director for cancer outcomes research at the UAB Comprehensive Cancer Center. “We and others have shown in our research studies that our cancer survivors are a vulnerable population,” she said. “When you follow them long-term, you find that they have a very high burden of chronic health conditions.”Often, these health problems can be linked back to cancer treatments, including chemotherapy, radiation and even surgeries, Bhatia said. Because these complications can occur “many years after the completion of treatment,” they are called “late effects.” One example involves a particular class of chemotherapy drug known as anthracyclines. “We use these agents often because they are highly effective in a large variety of cancers,” Bhatia said. But research shows that patients who take these drugs have a high risk of developing congestive heart failure many years later.
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