Happy New Year to all! As we make (and break) many New Year’s resolutions this month, I’d like to talk about resolutions for quality.
I appreciate the challenges and pressures to get claims coded and out the door and meet productivity standards. I am sure many organizations think I live in an ivory tower and not in the real world. Let me just tell you that we all have some sort of productivity standards in our jobs for which we are held accountable (myself included). Finding the right balance means hitting the mark on productivity while still doing a quality job.
The dilemma lies in how we define a complete versus a “good enough” medical record. Providers may document “just enough” so the record reflects a fair sense of the patient’s conditions so that the patient may be cared for safely. CDI reviewers may review “just enough” to find opportunities to clarify inconsistent, missing and incomplete documentation. Coding professionals may code “just enough” to ensure they have captured the essence of the patient. If all (or some of us) are only doing “just enough,” we are at risk for not fully representing:
- The patient on this encounter
- This patient in the future (and likelihood of returning to the hospital within a short period of time)
- The overall acuity of our patient population (and likelihood of returning within a short period of time)
I strongly encourage organizations to make reasonable decisions on complete coding (such as the need to code “every” procedure or patient/family history codes). But beyond the limitations previously noted, organizations need to set standards for complete capture of all medical conditions that meet criteria for secondary diagnosis reporting.
I also advise organizations to encourage/educate providers to document fully. Explain to providers that complete documentation helps justify why some patients can’t stay out of the hospital despite the best care. It also more fully represents and helps identify vulnerable populations.
Finally, I recommend that organizations take a careful look at their CDI program goals and current metrics. We need to assure a more complete picture, even when we can’t directly measure the impact on a case-by-case basis (traditionally used to show our worth to an organization). Remember that quality metrics are the result of the entire organization’s great care…and great documentation and great capture of the clinical picture. HIM staff and CDI staff share part of the success (and failure) in quality scores. This should be acknowledged and rewarded, or honed when necessary.
Let’s resolve to improve completeness in 2016!
Cheryl Manchenton is a Senior Inpatient Consultant and Project Manager for 3M Health Information Systems.
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