Category Archives: Clinical Documentation Improvement

Concurrent Documentation Review; CDI; concurrent chart review; complications and comorbidities; MCCs; Co-morbidities; Severity of Illness; SOI; Risk of Mortality; ROM; documentation at the point of care; MS-DRGs; Medicare Severity DRGs; APR-DRGs; casemix; case mix index; CMI; risk adjustment; chart completion

Oh what a tangled web we weave…The impact of CDI and Coding part II

I previously discussed how selection of principal diagnosis may impact quality. This ripple effect (like a pebble on a pond) may occur when one works in a silo, ignoring other departments such as quality. If only the ripple effect was the lone “offender” in which CDI and coding may impact quality outcomes. Consider a spider web: intricately designed and seeming impervious. However, as strands get broken, the web collapses.

In review, CDI professionals and coders are tasked with obtaining and capturing a complete picture of the patient’s encounter for appropriate reimbursement, accurate reflection of severity of illness (SOI) and risk of mortality (ROM) and outcomes of care. Historical models of CDI programs and coding processes focused predominately on the first two tasks, without acknowledgement of how this may affect quality outcomes (potentially fracturing the spider web). Continue reading

Toss Those Pebbles Carefully…The Ripple Effect of CDI and Coding on Quality Outcomes

I have never been able to skip a stone, but I do enjoy watching the ripples expand until they disappear. Or do they?

Clinical documentation improvement (CDI) has been around for quite a while and the function has changed throughout the years. Initially, the focus was on appropriate financial reimbursement for resources provided to patients. As quality of care became more transparent, the scope expanded into accurate reflection of severity of illness and risk of mortality. Today, the role of clinical documentation has grown far beyond these two functions. Continue reading

Quality Reviews: Delivering Constructive Feedback

To many healthcare documentation specialists (HDS), the QA process can feel like being scored for an academic grade. This is because a medical transcriptionist’s performance review, and sometimes even their compensation, is affected by her quality scores. But as I have discussed in previous posts, quality in documentation is a team sport in which the dictator, HDS, QA reviewer, and final authenticator(s) are all expected to contribute their best efforts to the document. Although it is important to ensure that each individual is doing her part to generate complete and accurate documentation, quality reviews should be treated as an opportunity to provide education and feedback toward continuous quality improvement. Continue reading

National Medical Transcription Week: It’s time we thank the guardians of health record integrity

This week is National Medical Transcription Week, and I would like to thank all of the hardworking medical transcriptionists and other healthcare documentation specialists (HDS) who support physicians every day in creating complete, accurate, and high quality patient care documentation. This year’s theme is “Guardians of Health Record Integrity;” so I would like to highlight a very important but often overlooked part of the healthcare documentation process, quality assessment (QA).

Within the healthcare documentation process, there are three different workflows for QA: Continue reading

Listen up: How the healthcare documentation team can optimize quality

In my February post, “Can You Hear Me Now?” I shared a list of suggestions for physicians and other dictators to help improve documentation quality. This time around, I am going to focus on the healthcare documentation staff in HIM and transcription. There are many best practices that the healthcare documentation team can implement to assist with dictation and documentation quality, and they all fit into three major categories:

Set expectations

The best way to get the results you want is to spell out what you expect through standards, procedures, and best practices. The healthcare documentation team needs to set the tone for how the organization captures patient information by: Continue reading

ONC Leaders on Ensuring Data Quality

On February 26 I was fortunate to attend a summit on “The Decade of Health IT” at the HIMSS 14 conference in Orlando, FL. The summit was sponsored by the Certification Commission for Health Information Technology (CCHIT) and featured a panel discussion made up of the current and three former National Coordinators for Health Information Technology. As part of the dialogue, audience members were invited to tweet questions for the panel concerning the future of HIT. I asked a question concerning data quality and want to share the response with you.

This was my initial question:Jill Devrick, Tweet 1

It generated a discussion among the panelists, which I recorded. Here’s how the panel conversation played out: Continue reading

Can you hear me now? How dictation habits affect quality

Hot off the presses, my colleague Janice Jones and I contributed to an article on how healthcare documentation specialists (HDS) can address problems with dictation in this month’s For the Record magazine. The tips and tools discussed in the article are great for those who process the dictation via traditional transcription or editing of speech-recognized text. However, I would like to focus this post on best practices for dictators. Good dictation habits are a huge help to the team that provides transcription and editing services, and clear, complete dictation improves efficiency and quality like nothing else. So, to avoid the “back-and forth” with healthcare documentation services and clinical documentation improvement, here are some tips to consider. Continue reading

Healthcare Documentation: Drawing a Blank

No, I don’t have writer’s block. I just have blanks on my mind.

Healthcare documentation specialists (HDS) such as medical transcriptionists, speech recognition editors, or quality analysts insert a “blank” or “flag” into a document to indicate to a physician where information is missing, incorrect, or questionable. But are blanks good or bad? In a perfect world, the physician would dictate or directly enter the document clearly, accurately, and with all relevant details the first time around. However, life is messy, and clinicians are very busy human beings, so there are many reasons why resolution of blanks is a necessary part of the document creation process. The HDS’s eyes and ears are important to ensure the quality of the documentation. First and foremost, they look and listen for potential patient care and safety concerns, but they also ensure the patient’s story reflects the professionalism and integrity of the individuals and organizations involved in the patient’s care. Continue reading

Document Creation: A Key Player in Data Governance

I attended two AHIMA events this fall – the Health Information Integrity Summit back in September, and the Annual Convention and Exhibit in October. These events have prompted me to think about data governance – the people, processes, and technology that are put in place to create a framework for capturing data. My background in document creation workflows and technology makes me keenly aware of how quality issues can make or break the success of documentation processes further downstream in the cycle such as coding, analytics, and system interoperability.

I often hear the cliché “garbage in, garbage out,” being used to describe how bad content capture practices can lead to a myriad of problems when attempting to use captured data and documentation for decision making and quality improvement. Continue reading

The Q Factor

How do you know all of the elements are in place for high-quality healthcare documentation? Where is the “sweet spot” in which the people, processes, and technology come together to deliver the optimal mix of complete, accurate, and timely content? AHDI and AHIMA have identified seven contributors to documentation quality, all of which deserve careful consideration when designing a quality assessment program.

The Author: Physicians and other clinicians affect the quality of documentation more than anyone, or anything, else. Whether dictating or entering content directly, caregivers need to organize and articulate their thoughts so that the patient’s care, and the context around it, is clearly understood by the reader. Organizations need to have training and tools available to assist dictators with developing skills that enable them to follow standards and optimize the results being generated from their speech. Some challenges, such as pronounced accents, may always be present, but many bad habits can be improved or eliminated with practice. Continue reading