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

Present and Accounted For…Potentially Preventable Complications

We all know the phrase “First do no harm,” a philosophy that is a driving force in health care. In other words, if we do not do anything to improve the health of our patients during their stay, at least let’s not allow anything bad to happen to them on our watch. Continue reading

Where Would We Be Without Clinical Coders?

I’m sitting on a plane today, traveling through the air as a result of some very bright people that enabled this mode of transportation. I’m doing so safely, thanks to strict airport security practices. Many years ago, when more stringent airport security screening was established, I would listen to fellow travelers complain about the invasion of privacy, the maybe not-so-random searches and the added expense tacked on to everything. And the lines in security, oh the lines! However, as a frequent traveler I’m forever thankful for the process we flyers have to go through to ensure the safest passage possible. Continue reading

Better Living—and Documentation—Through Computer Assistance

Have you ever driven a car without power-steering? It’s quite a workout. We used to all drive without power-steering and for “entertainment” you had to spend ten minutes twisting a small dial back-and-forth trying to get a radio station to come in clearly, only to drive under a bridge and completely lose it. Now we’re on the verge of self-driving cars and I can stream an entire album saved in the cloud into my car just about anywhere and anytime I want. No more fine-tuning that pesky radio dial. Continue reading

My Wish List for HIMSS15: Bring Documentation into the Health IT Conversation

For the past two years, I have been fortunate to attend the HIMSS Annual Conference & Exhibition in both New Orleans and Orlando. HIMSS puts on a massive event for about 38,000 people, so it’s definitely a great place to learn and network around the newest technologies, trends, and solutions in healthcare information technology. HIMSS15 kicks off in Chicago on April 12, and although I am unable to attend this year, I’ve been thinking about the conversations and ideas I hope will be generated by the organizers, presenters and attendees. Continue reading

Observation Services: Documenting Medical Necessity (Part One)

I shudder to think about the compliance quicksand surrounding observation services. Regardless, I’m going to attempt to explain how to document medical necessity for observation services (OBS). Fortunately – or unfortunately – depending on how you look at it, documentation requirements for medical necessity for OBS is not the same for all payers. Continue reading

Partial Dictation: A Smart Compromise for Quality Documentation

Last month, AHDI created a new Facebook group called “SR Errors – Funny or Fatal?” as a forum for healthcare documentation specialists (HDS) to share speech recognition “bloopers” that they caught during the editing process.

The submissions vary from hilarious:
“The patient slipped on the ice and fell on her Botox.”

To scary:
Dictated: “Lipitor 20, two pills a day”
Speech recognition result: “Lipitor 22 pills a day” Continue reading

It’s Complicated! Just Because You “Can” Doesn’t Mean That You “Should”

Remember as a child using the argument, “Everyone else’s parents are letting them” and your mother asking, “If everyone else jumped off a bridge, would you jump too?” When it comes to capture of diagnoses, the same type of argument can occur between HIM and Quality. Coding professionals will refer to the alphabetical/tabular indexes, official Coding Guidelines and AHA Coding Clinics for ICD-9-CM to support the capture of a diagnosis or for specific code assignment.  Quality staff will refer to the clinical picture, the probable intended meaning of the author and in applicable cases, the CDC diagnostic criteria as support for not assigning a code. I can remember a very passionate “discussion” between myself and a coding professional about a complication and whether or not it had to be assigned as a complication.  I stated, “Just because you can code it that way does not mean you have to code it that way!” Continue reading

The Oops Factor: Are Documentation Edits Nitpicky or Necessary?

In my last two “Oops Factor” posts, I discussed the necessity of addressing critical errors in healthcare documentation that could affect patient safety, as well as non-critical errors which may not harm the patient, but could impede the reader’s understanding of the content. But what about the nitpicky stuff? How far should editing go in the electronic world in which we now work?

I remember when I started consulting with hospital transcription departments almost 20 years ago that it mattered very much how the document appeared on paper and that every detail of spelling, grammar, punctuation, and other stylistic rules were maintained. Nowadays, adoption of speech recognition and direct EHR entry have fostered a new mindset of getting the documentation created as quickly as possible without worrying about minor issues. The advent of this mindset is in direct correlation to the expectation that the new technologies are efficient enough that physicians and other clinicians should create their own documentation without assistance. Continue reading

Whodunnit? Let’s be honest!

At the start of the New Year, I can’t help but reflect on how much patient care has changed in my 25+ years. Many things that were common practice back then were either not necessary or even sometimes harmful. An example would be Foley catheter placements. Foleys for “everyone” whether they needed them or not!

However, the advent of superbugs with increasing antibiotic resistance has also meant an increase in catheter-related UTIs. Organizations became focused on prevention, using different catheter materials thought to prevent colonization, and by evaluating the need for insertion and/or continued placement. It certainly didn’t hurt that catheter-associated UTIs (CAUTIs) were determined to be hospital-acquired preventable conditions that CMS would not reimburse, and were also factored into quality outcomes metrics by quality assessment programs or organizations. Continue reading

The Oops Factor Part 2: Noncritical Errors

Back in September, I wrote a blog about documentation errors and listed various types of critical errors that could potentially impact patient safety, care, or treatment. Clearly, errors that can cause harm are the first and most important to detect and resolve. Some errors don’t carry such severe potential consequences, but they still impact documentation quality.

Why should we be concerned about noncritical errors if their presence does not hurt the patient? First, these errors can affect perception about the author and/or organization if they are not addressed and corrected, especially if frequent or habitual. No physician or administrator wants to be questioned in court concerning incomplete, inaccurate, or just plain sloppy documentation because it introduces doubt regarding the attention to detail and professionalism of the organization and individuals providing care to the patient. Continue reading