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Clinical Documentation in the Inpatient Setting
Clinical Documentation in the Inpatient Setting
Outline
• Documentation For Compliance• Rules of the Road• Clinical Documentation Improvement
Program (CDIP)• Documentation Examples
Documentation For Compliance
H&P Required Elements
• Chief Complaint• History of Present Illness• Past Medical History• Medications• Allergies• Immunizations• Family Medical History • Social History
• Substance Use• Review of Systems• Physical Examination• Labs & X-ray Findings• Analysis of Admitting Problems• Problem List• Plan• Consultations
Must be completed within 24 hours of admission or 30 days prior to with update day of admission
Common Issues with H&P
• Handwritten H&Ps: Document not dated/signed
• Incomplete Reports: Missing physical evaluation, past medical history, and plan
• Forget to update the H&P at the time of admission if documented within past 30 days
Discharge Summary Elements
• Name of attending physician
• Patient Name• Admit Date• Discharge Date• Principal Diagnosis• Principal Procedure• Hospital Course
• Condition on Discharge• Activities• Diet• Follow-up Appointments• Medications• Copies of Summary sent to
(PCP, Referring Physician, Consultants)
Due the Day of Discharge
Common Issues with Discharge Summary
• Common Missed Elements• Admit Date• Condition on Discharge• Activities• Diet
Brief Post Op Note Elements
• Name of surgeon, proceduralist, and assistants• Procedure performed and a description of the
procedure• Findings• Estimated blood loss• Specimen(s) removed• Postoperative diagnosis
RC.02.01.03
Common Issues with Brief Post Op Note
• “Findings” left blank• Doctors must amend or attest for anything done by
medical student• All paper brief post op notes must be signed, dated,
and timed by doctor
Contact InformationLinda McNeil, Assistant Director of
MIS
322-3857Adult Medical Records Hub
322-2205 and 343-3060History & Physical contact information
Ben Giles 343-1659Discharge Summary contact information
Alisa Maloney 343-4449Brief Post Op Note contact information
Adult Medical Records Hub322-2205 and 343-3060
Linda McNeil, Assistant Director of MIS
322-3857VCH Medical Records Hub
936-5278 VCH History & Physical contact
information
Amaris Scott 343-8510VCH Discharge Summary contact
information
Amaris Scott 343-8510VCH Brief Post Op Note contact
information
VCH Medical Records Hub936-5278
Rules of the Road
The Purpose of the Medical Record is:
• to serve as a basis for planning patient care and for continuity in the evaluation of the patient's condition and treatment;
• to furnish documentary evidence of the patient's medical evaluation, treatment, and change in condition during the hospital stay, during an ambulatory care or emergency visit to the hospital;
• to document communication between the responsible practitioner and other health professionals who contribute to the patient's care;
• to assist in protecting the legal interest of the patient, the hospital and the responsible practitioner;
• to document for the purposes of third party payment that a test or procedure is medically necessary, has been ordered, has been done, and a result (in the case of tests) is in the chart.
TDKD• The history, examination and decision making process
for diagnosis and treatment are the key elements of a provider’s note for each patient encounter. Those key elements should be concisely described in the note using the following points (referred to as TDKD) concisely:
• What the author Thought about each issue• What the author Did about each issue• What others need to Know about each issue• What others need to Do about each issue
Clinical Documentation Improvement Program (CDIP)
What Is A Clinical Documentation Improvement (CDI) Program ?
• A CDI program is designed to improve inpatient record documentation by establishing a coordinated, systemic process utilizing a concurrent review team to strengthen communication between caregivers, physicians and the coding professionals
• Ensure that the clinical documentation in the patient record accurately reflects the patient’s principal diagnosis (reason for admission)
• Secondary diagnoses (co morbid conditions) are documented• Capture procedures performedProvide an accurate picture of the patient’s acuity, severity of
illness, and expected chance of mortality for this particular hospitalization
Why Implement A Clinical Documentation Improvement Program?
• New laws and regulations, ongoing federal reforms, and payer initiatives are increasingly aligning quality outcomes with financial incentives and reimbursement
• Medicare and many third-party insurers now consider patient severity of illness and post-admission complications when calculating payment
• At the same time, accurate capture of patient acuity and risk of mortality impacts your hospital’s case mix index (CMI), which influences quality outcomes and hospital performance reports made available to consumers
Secondary Conditions Are:
- additional conditions that affect patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extend the length of stay, or increase nursing care and/or monitoring – “ resource utilization”
• In addition these conditions also affect the expected mortality % assigned to each discharge
- These conditions are referred to as “major co morbid conditions”(MCC) or “co morbid conditions” (CC)
Do Severity and Risk Adjustment Really Make a Difference?
PRINCIPAL DIAGNOSIS & Procedure: Subarachnoid Hemorrhage with Repair of Aneurysm
Original Documentation Additional Documentation
Secondary Diagnosis Occlusion Specf Artery W InfarctionAphasiaCOPDABLARepair of Aneurysm Vent > 96 hours
Occlusion Specf Artery W InfarctionAphasiaCOPDABLAComa
Acute Respiratory Failure
Repair of Aneurysm Vent > 96 hours
APR DRG 21 Craniotomy Except for Trauma21 Craniotomy Except for Trauma
APR DRG Severity of Illness 3 Major (Weight 4.7570) 4 Extreme (Weight 8.6888)
APR DRG Risk of Mortality 1 Minor 4 Extreme
APR DRG Risk of Mortality % 0.0064%. 0.4438%
Impact of MCCs and CCs on a Neurosurgery DRG
Intracranial Vascular ProceduresDRG 528 Weight 7.0543
MS-DRG 20 Intracranial Vascular Procedures With A PDX of Hemorrhagic(with a major co morbid condition)
Coma
-Weight 7.7073
MS-DRG 21 Intracranial Vascular Procedures With A PDX of Hemorrhagic(with a co morbid condition)
Cachexia
-Weight 6.7021MS-DRG 22 Intracranial Vascular Procedures With A PDX of Hemorrhagic(without a major co morbid condition or co morbid condition)
-Weight 5.6085
V24 DRG
Do Document
* Significant acute diseases
*Acute exacerbation of significant chronic diseases
* Advanced or end stage chronic diseases
* Chronic diseases associated with a systemic physiologic decompensation and extensive debility
Definitions Mortality O/E
Observed mortality – actual inpatient deaths Expected mortality – those inpatients who are
expected to die during the hospitalization based on the clinical documentation in the medical record
OE Ratio – The number of observed deaths divided by expected mortalities
VUMC UHC O/E Mortality by month (Oct 2005-May 2009)
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
2005
-10
2005
-11
2005
-12
2006
-01
2006
-02
2006
-03
2006
-04
2006
-05
2006
-06
2006
-07
2006
-08
2006
-09
2006
-10
2006
-11
2006
-12
2007
-01
2007
-02
2007
-03
2007
-04
2007
-05
2007
-06
2007
-07
2007
-08
2007
-09
2007
-10
2007
-11
2007
-12
2008
-01
2008
-02
2008
-03
2008
-04
2008
-05
2008
-06
2008
-07
2008
-08
2008
-09
2008
-10
2008
-11
2008
-12
2009
-01
2009
-02
2009
-03
2009
-04
2009
-05
% Deaths (Obs) % Deaths (Exp) Mortality Index
Concurrent Review Process• The CDC staff will query when they suspect a complication or co morbidity
exists but has not been documented or specificity is required. The primary mode of contact is in email form. Occasionally the queries may be verbal.
• The CDC staff enters the data into our tracking software. A report is then generated monthly that gives the percent of the time that a particular service and/or clinician responded to the query and what particular diagnosis the CDC was looking for.
• This report is sent to the Chief, Chair, department head or designee to review and report out to the faculty. The queries are tracked as being “Agree” (with subsequent documentation of the diagnosis in the medical record), “Disagree” meaning that the clinician didn’t agree with the query, “unknown” meaning the clinician was asked but doesn’t know, and “No response”.
• We ask that if the provider disagrees with the query or believes that the query needs to go to another provider that they let us know immediately so that we can contact the appropriate physician with our query. Please do not ignore the query
Documentation Examples
Documentation of Heart Failure requires acuity, side, systolic/diastolic and etiology when known.
• Acute systolic heart failure• Acute on chronic systolic heart failure• Acute diastolic heart failure• Acute on chronic diastolic heart failure• Acute combined systolic and diastolic heart failure• Acute on chronic combined systolic and diastolic heart failure• Left heart failure• Unspecified systolic heart failure• Chronic systolic heart failure• Unspecified diastolic heart failure• Chronic diastolic heart failure• Unspecified combined systolic and diastolic heart failure• Chronic combined systolic and diastolic heart failure
Acuity = “acute”, “chronic”, “combined”Side = “right”, “left”, “combined”
Acuity = “acute”, “chronic”, or “combined”Side = “right”, “left”, or “combined”
History & Physical
• Assessment and Plan:
• Ms. X is a 73 year old female with h/o HTN, COPD, Dementia and brain and lung cancer presenting w/ 2 days of dyspnea and wheezing. No signs or symptoms suggestive of pneumonia. Suspect
COPD/emphysema exacerbation.
FINAL NOTE AND DISCHARGE SUMMARY
• Synopsis/Reason for Hospitalization/Principle Diagnosis:
Synopsis:: Ms. X is a 73 year old female with h/o HTN, COPD, Dementia and brain and lung cancer presenting w/ 2 days of dyspnea and wheezing. No signs or symptoms suggestive of pneumonia. Suspect COPD/emphysema exacerbation. CXR showed bibasilar opacities. Ready for discharge home with family today.Diagnosis/Hospital Course/Treatment: COPD exacerbation [resolved]: - continue supplemental oxygen- continue nebulizers- prednisone 40mg daily, tapering- Resolved with treatment
Community-acquired pneumonia: - CXR showed increased bibasilar opacities- started on oral Levaquin, will finish course at home Disposition: - resides at home with family- SW aware- ready for discharge home with family today- spoke with family in room before discharge and updated on medication changes and new abx, very agreeable and will have patient follow-up with PCP
Example
• PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished man who appears comfortable, and in no apparent distress.
• VITALS: Temp: 96.0 deg FP: 94 RR: 18 BP: 128/93 Height: 72.1 in (10/22/09) Weight: 108.91 lb (11/17/09) O2 sat: 100 % on room air
• Cachetic man lying in bed in NAD, has just vomitted small amount of non-bloody, non-bilious emesis course
• BS bilaterally rrr, 0 m/r/g • abdomen soft, mildly distended. no peritonitis
Pt. weight 108#, height 6’1”- has esophageal cancerThe conflicting documentation was in the same progress note
