Find Your Routine: Know Your Client Workflow

by | Jan 15, 2019 | Education, Find Your Routine, ICD-10, Series | 0 comments

When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our series, Find Your Routine, we interviewed our most productive coders and asked them what steps they take to find a rhythm that works for them. 

This week, we talked with Tilina Sablan, RHIT, CCS, Coding Specialist with Health Information Associates, about the steps she takes to find her routine.


 

Tilina Sablan, RHIT, CCS, is a Coding Specialist with Health Information Associates

Tilina Sablan, RHIT, CCS, is a Coding Specialist with Health Information Associates

Q: Describe in detail your daily routine.

A: First thing in the morning, I check both my client e-mail and HIA e-mail. If there is anything administrative related that needs my attention, I take care of that right away. Next, I look at any pending charts that are outdated and need to be reviewed and I follow up on those. Since I am in touch with CDI a lot at my current client, I also like to check that e-mail first thing.

Finally, it’s time to start coding!

I begin with the discharge disposition in PowerChart, then I abstract the attending and consults. I go through the workflow that the client provides. Every client is different, so I find it important to get to know your client and their workflow. This ensures I don’t miss anything that needs to be coded. From there, I open 3M and review CDI notes to get a glance at what kind of chart I will be coding. After reviewing, I will go through their final notes. From there I go into PowerChart and review entire the H&P to get admitting diagnosis, then ED, discharge summary, consults, op notes, progress notes, etc. After reading all of that, I go back to the discharge summary to make sure I got the correct principle diagnosis and secondary diagnoses – making sure I’ve captured everything. My client uses CAC system that I do use; however, if I’m not sure if it’s the right code, I will use The Coding Tree. If there are some codes that they are suggesting for me, I will look up those codes to verify and be sure that they are appropriate secondary diagnoses to report.

If I know there is a chart that I will have questions on, I open SharePoint and put in the main terms or terms that will help narrow down the search. I read what relates to what I am coding to familiarize myself with the chart I am about to code. This all helps to make sure I am selecting the correct principle diagnoses.

If I still have a question and don’t find a similar tip, I will save all the notes and send my questions to Sharepoint so our HIA Education team can provide that extra help and clarity.

Q: How do you maintain your routine day after day, week after week?

A: I make sure to do things that encourage me to focus. In the beginning of my work day, I like to listen to the radio and morning talk shows until about 10 a.m. – it helps get me motivated for the day. Depending on what charts I get, like new moms and babies, I try to attack those by spending less of my coding time. This allows me to spend longer on those charts that require more time, like longer length of stays

Q: What techniques have you found to minimize distractions?

A: In the morning, I make sure to keep my water and a snack nearby so I don’t have to get up and then get sidetracked. Just being ready for the day and prepared to work is the best tip I can give. I must keep my phone around me for my kids, but I always get in that work mind set and have what I need to attack my work day and prepare to code.

Q: What are the productivity goals that you set for yourself? And how do you track them?

A: I feel that productivity is a never ending challenge and I am always striving to improve. I always want to make the most of my day – finishing that last record or trying to fit in one more chart before the days end. I also found the speed-reading tip and action plan very helpful. Another trick I use is writing down tips and coding shortcuts on digital sticky notes on my desktop (example below). This prevents me from having to go online and research the same thing twice – it’s just right there in front of me.

Q: What motivates you the most? Positive feedback from managers, self-motivation by reaching personal goals, financing incentives? Or other?

A: Positive feedback from managers and self-motivation works best for me. I love getting positive feedback from clients – that motivates me the most. I like to hear that I am doing a good job, and any constructive feedback.


 

TIP: Use digital sticky notes on your desktop to write down tips and coding shortcuts. Below is an example of Tilina’s:

example of medical coding notes

Pin It on Pinterest

Share This