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Clinical Documentation in the InpatientSetting

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Outline

• Documentation For Compliance• Rules of the Road• Clinical Documentation Improvement

Program (CDIP)

• Documentation Examples

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Documentation For Compliance

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!P Re"uired Elements

• Chief Complaint•

History of Present Illness• Past Medical History• Medications• Allergies• Immunizations• Family Medical History• Social History

• Substance Use•

e!ie" of Systems• Physical #$amination• %abs & '(ray Findings• Analysis of Admitting Problems• Problem %ist• Plan• Consultations

#ust $e completed %ithin &' hours of admission or da*s prior to %ith update da* of admission

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Common Issues %ith !P

• Hand"ritten H&Ps)*ocument not dated+signed

• Incomplete eports)Missing physical e!aluation, past medical history, and plan

• Forget to update the H&P at the time of admission ifdocumented "ithin past -. days

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Discharge Summar* Elements

• /ame of attendingphysician

• Patient /ame• Admit *ate• *ischarge *ate

• Principal *iagnosis• Principal Procedure• Hospital Course

• Condition on *ischarge

• Acti!ities• *iet• Follo"(up Appointments• Medications• Copies of Summary sent to

0PCP, eferring Physician,Consultants1

Due the Da* of Discharge

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Common Issues %ith DischargeSummar*

• Common #issed Elements

• Admit *ate• Condition on *ischarge• Acti!ities• *iet

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+rief Post Op ,ote Elements

• /ame of surgeon, proceduralist, and assistants

• Procedure performed and a description of theprocedure• Findings

• #stimated blood loss• Specimen0s1 remo!ed• Postoperati!e diagnosis

RC.02.01.03

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Common Issues %ith +rief Post Op,ote

• 2Findings3 left blan4• *octors must amend or attest for anything done by

medical student

• All paper brief post op notes must be signed, dated,and timed by doctor

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Contact Information-inda #c,eil. /ssistant Director of#IS

-55(-678/dult #edical Records u$

-55(55.7 and -9-(-.:.

istor* ! Ph*sical contact information ;en Discharge Summar* contact information Alisa Maloney -9-(999>+rief Post Op ,ote contact information

Adult Medical ecords Hub-55(55.7 and -9-(-.:.

-inda #c,eil. /ssistant Director of #IS-55(-678

0C #edical Records u$>-:(7586

0C istor* ! Ph*sical contact information

Amaris Scott -9-(67=.0C Discharge Summar* contact

information Amaris Scott -9-(67=.0C +rief Post Op ,ote contact

information

?CH Medical ecords Hub>-:(7586

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Rules of the Road

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1he Purpose of the #edical Record is2

• to serve as a $asis for planning patient care and for continuit* inthe evaluation of the patient3s condition and treatment4

• to furnish documentar* evidence of the patient3s medicalevaluation. treatment. and change in condition during the

hospital sta*. during an am$ulator* care or emergenc* visit tothe hospital4• to document communication $et%een the responsi$le

practitioner and other health professionals %ho contri$ute to thepatient3s care4

• to assist in protecting the legal interest of the patient. thehospital and the responsi$le practitioner4

• to document for the purposes of third part* pa*ment that a testor procedure is medicall* necessar*. has $een ordered. has $eendone. and a result (in the case of tests) is in the chart5

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@* *

• 1he histor*. examination and decision ma6ing processfor diagnosis and treatment are the 6e* elements of aprovider7s note for each patient encounter5 1hose 6e*

elements should $e concisel* descri$ed in the noteusing the follo%ing points (referred to as 1D8D)concisel*2

• Bhat the author 1hought about each issue

• Bhat the author Did about each issue• Bhat others need to 8 no" about each issue• Bhat others need to Do about each issue

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Clinical Documentation ImprovementProgram (CDIP)

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9hat Is / Clinical DocumentationImprovement (CDI) Program :

• / CDI program is designed to improve inpatient recorddocumentation $* esta$lishing a coordinated. s*stemic process

utili;ing a concurrent revie% team to strengthen communication$et%een caregivers. ph*sicians and the coding professionals• Ensure that the clinical documentation in the patient record

accuratel* reflects the patient7s principal diagnosis (reason foradmission)

• Secondar* diagnoses (co mor$id conditions) are documented• Capture procedures performedProvide an accurate picture of the patient7s acuit*. severit* of

illness. and expected chance of mortalit* for this particularhospitali;ation

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9h* Implement / ClinicalDocumentation Improvement Program:

• New laws and regulations, ongoing federal reforms,

and payer initiatives are increasingly aligning qualityoutcomes with financial incentives andreim ursement

• !edicare and many third"party insurers nowconsider patient severity of illness and post"

admission complications when calculating payment• #t the same time, accurate capture of patient acuity

and ris$ of mortality impacts your hospital%s casemi& inde& 'C!(), which influences quality outcomesand hospital performance reports made availa le toconsumers

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Secondar* Conditions Are:

( additional conditions that affect patient care in terms ofre"uiring clinical evaluation. therapeutic treatment.diagnostic procedures. extend the length of sta*. or

increase nursing care and resourceutili;ation?

• In addition these conditions also affect the expectedmortalit* @ assigned to each discharge

( 1hese conditions are referred to as >maAor co mor$idconditions?(#CC) or >co mor$id conditions? (CC)

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Do Severity and Risk Adjustment Really Makea Difference?

PRINCIPAL DIAGNOSIS & Procedure: Subarachnoid Hemorrhage withRepair o Aneur!"m

Original Documentation Additional Documentation

Secondar* Diagnosis cclusion Specf Artery B InfarctionAphasiaC P*A;%A

epair of Aneurysm?ent D >: hours

cclusion Specf Artery B InfarctionAphasiaC P*A;%A

Coma /cute Respirator* Failure

epair of Aneurysm?ent D >: hours

/PR DRB 5= Craniotomy #$cept for @rauma5= Craniotomy #$cept for @rauma

/PR DRB Severit* of Illness - MaEor 0Beight 9 878.1 ' Extreme (9eight 5 )

/PR DRB Ris6 of #ortalit* = Minor ' Extreme

/PR DRB Ris6 of #ortalit* @ . ..:9G 5'' @

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Impact of #CCs and CCs on a,eurosurger* DRB

Intracranial VascularProcedures DRG 528Weight 7.0543

M !DRG 20 IntracranialVascular Procedures With "

PD# o$ %e&orrhagic '(ith a &a)or co &or*idcondition+

,o&a

!Weight 7.7073

M !DRG 2- IntracranialVascular Procedures With "PD# o$ %e&orrhagic '(ith a co &or*id condition+

,ache ia

!Weight /.702-

M !DRG 22 IntracranialVascular Procedures With "PD# o$ %e&orrhagic '(ithout a &a)or co &or*idcondition or co &or*idcondition+

!Weight 5./085

V24 DRG

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Do Document* Significant acute diseases

/cute exacer$ation of significant chronicdiseases

/dvanced or end stage chronic diseases Chronic diseases associated %ith a s*stemic

ph*siologic decompensation and extensivede$ilit*

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Definitions #ortalit* O

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Concurrent Revie% Process• 1he CDC staff %ill "uer* %hen the* suspect a complication or co mor$idit*

exists $ut has not $een documented or specificit* is re"uired5 1he primar*mode of contact is in email form5 Occasionall* the "ueries ma* $e ver$al5

• 1he CDC staff enters the data into our trac6ing soft%are5 / report is thengenerated monthl* that gives the percent of the time that a particular serviceand/gree? (%ithsu$se"uent documentation of the diagnosis in the medical record).>Disagree? meaning that the clinician didn7t agree %ith the "uer*. >un6no%n?meaning the clinician %as as6ed $ut doesn7t 6no%. and >,o response?5

• 9e as6 that if the provider disagrees %ith the "uer* or $elieves that the"uer* needs to go to another provider that the* let us 6no% immediatel* sothat %e can contact the appropriate ph*sician %ith our "uer*5 Please do notignore the "uer*

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Documentation Examples

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Documentation of eart Failure re"uires acuit*. side.s*stolicacute?. >chronic?. or >com$ined?Side G >right?. >left?. or >com$ined?

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istor* ! Ph*sical

• /ssessment and Plan2

• Ms ' is a 8- year old female "ith h+o H@/, C P*, *ementia and

brain and lung cancer presenting "+ 5 days of dyspnea and "heezing /o signs or symptoms suggesti!e of pneumonia Suspect

C P*+emphysema e$acerbation

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FI,/- ,O1E /,D DISC /RBES ##/RH

• S*nopsis

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Example

• / -(C# #!(N#4(5N6 7 N R# 6 Well-developed, well-nourished man who appearscomfortable, and in no apparent distress.

• 8(4# -6 Temp: 96. de! "#: 9$ %%: &' (#:&)'*9+ ei!ht: ).& in & *))* 9/ Wei!ht: & '.9&lb &&*& * 9/ 0) sat: & 1 on room air

• 2achetic man l3in! in bed in 45 , has 7ustvomitted small amount of non-blood3, non-

bilious emesis course• (8 bilaterall3 rrr, m*r*!• abdomen soft, mildl3 distended. no peritonitis

Pt5 %eight N . height 7N?M has esophageal

cancer1he conflicting documentation %as in the samero ress note

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uestions:

• 8tephanie.5. a3s anderbilt.edu• +))- 66+

mailto:Stephanie.A.Hays@Vanderbilt.edumailto:Stephanie.A.Hays@Vanderbilt.edu