Boise Clinical Documentation Improvement
Boise Clinical Documentation Improvement
Boise Clinical Documentation Improvement
Sample websites:
www.RateMDs.com
www.DrScore.com
www.HealthGrades.com
3
www.vitals.com
How are physicians profiled?
4
How are physicians profiled?
Physician profiles
should accurately
reflect their
patient’s SOI and
ROM, confirming
the excellent care
they provide…
Average
CMI LOS
Dr. Smith 1.8 6 days
Total Number
CMI Of Case
Fatalities 2010
Dr. Smith 1.8 5
7
What is the Documentation Clarification process?
CC
CC
• How about: “75 y/o with COPD and chronic
respiratory failure; now complicated by acute
pneumonia, probably Gram negative in view of
age, underlying disease and recent MCC
• The medical record reflects the following clinical findings, treatment, and risk factors.
• Risk factors: s/p motorcycle injury
• Clinical factors: multiple open fractures to UE and large soft subq abdominal hematoma, initial HCT 39.8, postop drop to 18.8
• Treatment: serial HCTs, ICU monitoring, surgery for repair injuries, and transfusion of 6 units blood and 2 units FFP
• Please clarify and document your clinical opinion in the progress notes and discharge summary including the definitive and/or presumptive diagnosis, (suspected or probable),
related to the above clinical findings. Please include clinical findings supporting your diagnosis.
• ____________________________________________________
• If you need further assistance please refer to the following:
• Additional helpful information placed here for your reference.
Who are we?
Jill Hawkins, RN, Mary Jo Kichak RN, Mendy Mestas Dara Hemphill RN, CDS
CDS CDS RN, CDS Ext. 8995
Ext. 7182 Ext-8987 Ext. 7173
RN CCDS RN CCDS
Medical
POA/HAC Necessity
Adm / Compliance
Obs
Core Outcome
Team Effort: Measures Measures
CM, UR, CDS/Coders, Staff Nurses, Patient
NP/PAs, Residents & Physicians all Safety
working together to “Tell the Story
of our patients”
Copyright 2011 Trinity Health - Novi, Michigan 13