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Collaborative Documentation Improvement
What Are the Necessary Elements
Defining Clinical Documentation Improvement-
An Arduous Task
Defining clinical documentation improvement in the health record can be arduous, depending upon the mindset and viewpoint of the individual interpreting the definition. Clinical documentation improvement from a hospital’s chief financial officer’s perspective entails improved documentation of comorbidities/complications or Major comorbidities/complications that facilitate enhanced ICD-9 code and MSG-DRG assignment, thereby enhancing revenue generation for the hospital. Defining clinical documentation improvement assumes competing viewpoints in the minds of quality improvement professionals. Clinical documentation improvement in the context of quality improvement embraces the notion of specific, accurate, and detailed clinical documentation in support and reflection of accurate reporting of patient acuity, risk of morbidity and mortality, risk of readmission to the hospital, measures of fail to rescue, death within 48 hours of hospital admissions, Medicare Core Measures, and measures of patient safety indicators to just name a few. The completeness and accuracy of clinical data is instrumental in and the foundation for driving clinically relevant outcomes studies that are more commonly becoming publicly available on such websites and hospitalcompare.gov and whynotthe best.org. Lastly, the definition of clinical documentation improvement incorporates thoughts of improved physician documentation of patient severity of illness and intensity of service in support of commercially available screening criteria such as Interqual and Millman utilized in determining medical
Clinical Documentation Improvement
The Collaborative Approach
Clinical documentation improvement initiatives can meet the competing definitional forces by focusing upon collaboration in achieving the underlying key principles of medical record documentation, that is “reasonable and medically necessary” and “supporting documentation.” Collaboration may be defined as a cooperative arrangement in which two or more parties (which may or may not have any previous relationship) work jointly towards a common goal. The goals and objectives of a clinical documentation program can embrace collaboration if structured properly and incorporate meaningful buy-in from the physician audience in promotion of their participation.
A primary challenge that poses a road block for typical clinical documentation improvement program initiatives is the primary focus upon securing additional revenue for the hospital to the extent most physicians view the program as strictly a “hospital driven” initiative. Collaboration can be effectively integrated into the roots of the clinical documentation improvement program by training and educating the clinical documentation improvement specialists on the merits of concise, clear, and clinically relevant clinical documentation to the physician’s business of the practice of medicine. The same level of detailedness, specificity and completeness in clinical documentation necessary to support reasonable and necessary inpatient admissions as well as observation services in the hospital is required for the physician’s reporting of their practice of medicine through documentation an establishment of medical necessity for reporting of Evaluation and Management services. Collaboration entails the phsyician and the clinical documentation improvement specialists working together to affect positive change in behavior modification of overall physician patterns of clinical documentation.
Clinical documentation improvement specialists area of clinical specificity focus can include but not be limited to completeness and accuracy of Emergency Room physician documentation, adequacy and effectiveness of the History of the Present Illness portion of the History and Physical, Assessment and Plan portion of the History and Physical, consistency and follow-through in documentation of clinically relevant acute and chronic clinical conditions being managed throughout the course of daily progress notes, and completeness of discharge summary that incorporates all relevant diagnoses and conditions managed throughout the stay with chronological outline and timeframe beginning with the initial presentation of the patient to the hospital.
Disparate Definitions of Clinical Documentation Improvement
The reality of clinical documentation improvement initiatives is that what appears on face value to be disparate and competing definitions governing clinical documentation improvement are actually congruent in form and function. Complete and accurate clinical documentation throughout the record that incorporates specificty in both acute and chronic clinical diagnoses, severity of patient’s clinical signs and symptoms at presentation to the hospital, clear outline of physciian’s clinical judgment and medical decision making throughout the record, provisional diagnoses and working hypotheses at time of patient admission, rationale for diagnostic workup including clinical significance of abnormal results in support of further workup and plan of treatment, and risk factors presented by patient current comorbid consitons and past medical history, serves all the different and varied constituents of clinical documentation. The byproduct of this improved clinical documentation is enhanced resimbursement for the hospital more closely proximating hospital resource consumption in line with patient clinical complexity. By definition, a complete and accurate clinically documented record embraces the concept of Res Ipsa Loquitur- “The Thing Speaks for Itself.”