Clinical documentation improvement - a nursing role?

Abstract

If I had been told 20 years ago that my future nursing role would be reading inpatient notes to look for missing diagnoses of comorbidities and complications that clinicians were actively treating, I would have said no way! I would have been working at a very busy Melbourne Emergency Department at the time, living off adrenaline in a high-pressure environment with an amazing team. Together we received comprehensive training through the Hospital's Health Information Management (HIM) Department. If we delivered the role as an audit or sent retrospective documentation queries via email to confirm treatment and a diagnosis, the clinical engagement would not be there, and clinical documentation improvement would be just another chore.