Carol S. Gifford MSN, RN, CPHQ Quality Improvement Nurse Institute for Healthcare Quality & Innovation University Hospitals Case Medical Center Sue Ryan RN, CPAN, BSN Quality Improvement Nurse Institute for Healthcare Quality & Innovation University Hospitals Case Medical Center Kelly Skorepa BSN, RN, CCDS Corporate Manager, Clinical Documentation Improvement University Hospitals Redesign the Paradigm: Efficient Clinical Documentation in an Electronic World Kristen Bates MBA, RHIA, CCS, CDIP Corporate Manager Health Information Services University Hospitals Sally Streiber BS, MBA, CPC, CEMC Manager, Coding Compliance and Education, Compliance and Ethics Department University Hospitals Erica E Remer, MD, FACEP, CCDS Physician Clinical Documentation Education Coordinator University Hospitals Raymond Krncevic, Esq. Associate General Counsel Sara Hissong BS, RN Clinical Informatics Liaison, EMR Change Management
Transcript
Carol S. Gifford MSN, RN, CPHQQuality Improvement NurseInstitute for Healthcare Quality & InnovationUniversity Hospitals Case Medical Center
Sue Ryan RN, CPAN, BSNQuality Improvement NurseInstitute for Healthcare Quality & InnovationUniversity Hospitals Case Medical Center
Kelly Skorepa BSN, RN, CCDSCorporate Manager, Clinical Documentation ImprovementUniversity Hospitals
Redesign the Paradigm: Efficient Clinical Documentation in an Electronic World
Kristen Bates MBA, RHIA, CCS, CDIPCorporate ManagerHealth Information ServicesUniversity Hospitals
Sally Streiber BS, MBA, CPC, CEMCManager, Coding Compliance and Education, Compliance and Ethics DepartmentUniversity Hospitals
Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoatnt tihng is taht the frist and lsat ltteer be at the rghit pclae. The rset can be a toatl mses and you can sitll raed it wouthit a porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe.
November 22, 2014 University Hospitals
ONE IS A MISTAKE; MORE IS A MESSNovember 22, 2014 University Hospitals
I don’t have time to document well
November 22, 2014 University Hospitals
Fact or Fiction?Fact or Fiction?
• Legal• Timing is everything• Internal inconsistencies• Right hand doesn’t know what the left
hand is doing• Rationale• Lack of specificity
November 22, 2014 University Hospitals
Do you have time NOT to?!Do you have time NOT to?!
• Denials
• Utilization Review
• Clinical Documentation Integrity Queries
• Audits
November 22, 2014 University Hospitals
Do you have time NOT to?!Do you have time NOT to?!
Substance is more important than length
November 22, 2014 University Hospitals
Tell the Story!Tell the Story!
Service: Cardiology Subjective Data: is a 84 year old Female who is Hospital Day #6.
Pt seen and examined at bedside. She has AD, poor historian. Pt appears comfortable.
Overnight Events: Patient had an uneventful night.
November 22, 2014 University Hospitals
(Non) Progress note(Non) Progress note
Chief Complaint: Patient comes in for a routine checkupF/U on DM and HTN; also c/o left sided chest pain History of Present Illness:Pt. has been notating his blood sugar for the past few weeks. Pt. came to discuss it with doctor.
November 22, 2014 University Hospitals
History?History?
Daily Progress Note [ ] – for Visit: , Final, Entered, Signed in Full, General
Subjective Data: is a 90 year old Female who is Hospital Day #2.
STOP THE BLOAT!November 22, 2014 University Hospitals
November 22, 2014 University Hospitals
Chief Complaint: Chest pain History of Present Illness:64 year old with history of previous MI 1999, c/o 1 week of intermittent achy 4/10 left sided chest pain with diaphoresis when walking his dog.
Duration, Timing, Quality, Severity, Location, Associated signs and symptoms, Context
November 22, 2014 University Hospitals
History?History?
November 22, 2014 University Hospitals
23
yesterday morning. Patient to ask in the breakfast, and 80, and feel well. After taking at its. There are related off to know when he was sitting at the at the dinner table and his granddaughter was in his lab and he started feeling a lot of nausea, belching, Margaret abdominal pain, even to the bathroom 3 times yesterday. He was not work today, via he denies, fever, chills, sweating.
November 22, 2014 University Hospitals
November 22, 2014 University Hospitals
5/28: ** Cardiomyopathy: - EF 25-30% on echocardiogram earlier in month- Re introduce hydralazine + will give 20 mg lasix IV once today- Will optimize HF meds
5/29: ** Cardiomyopathy: - EF 25-30% on echocardiogram earlier in month- Re introduce hydralazine + will give 20 mg lasix IV
once today- Will optimize HF meds
5/30: ** Cardiomyopathy:
- EF 25-30% on echocardiogram earlier in month
- Re introduce hydralazine + will give 20 mg lasix IV once today
- Will optimize HF meds
November 22, 2014 University Hospitals
“May use macros,… but must provide customized info that is sufficient to support a medical necessity determination. ..must sufficiently describe the specific services furnished to the specific patient on the specific date. If both the resident and the teaching physician use only macros, this is considered insufficient documentation.”
– What has happened?– How is the patient feeling?– Have the symptoms changed?– Any clinical events of note?
• Observations (PE and testing)– Document your work-product– Make templates
• Analysis and Plan (MDM)– Status (original problem, new issues)– Interpretation of tests, procedures– Medical necessity for new orders– Focus of treatment– Documentation of definitive diagnoses
• Most important part of the documentation
• Don’t regurgitate the HPI or the interval history
• Synthesize, analyze
• Readable
• Consultants need to be clear on recommendations
• Evolving (progress notes). Don’t C&P the same assessment and plan every day.
November 22, 2014 University Hospitals
Analysis & PlanAnalysis & Plan
November 22, 2014 University Hospitals
• Evolve diagnoses
• Resolve diagnoses
• Recap major diagnoses in discharge summary
November 22, 2014 University Hospitals
Analysis & PlanAnalysis & Plan
November 22, 2014 University Hospitals
Don’t Attest, Don’t Attest, Invest!Invest!
• An unsigned note is an unbillable service
• Resident documentation without attestation is an unbillable service
• Unattested and/or unsigned notes cannot be utilized to support any other service
• The date of service can be adjusted if you are signing on a different day, presuming you SAW the patient on the earlier day
November 22, 2014 University Hospitals
Attestation and SignatureAttestation and Signature
Documentation Audit ToolDocumentation Audit Tool5
Chief Complaint Explicit Statement
Historical Narrative Advances understanding of why patient is still in hospital
PE PE appropriate to condition, accurate, identifiably unique
Data Acquisition and Interpretation Appropriate testing, reviewed and analyzed
Assessment (Diagnoses) Clear analysis and synthesis; all problems current with appropriate diagnoses
Plan All identifiable problems with reasonable, clear plans; MDM commensurate with severity
Attending Input Attending generated or additional added-value documentation and signed within 24 hours
Succinctness No gratuitous C&P, no import of irrelevant info
