Boise Clinical Documentation Improvement

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Clinical Documentation Improvement:

Why does it matter?

Clinical Documentation Specialist


Physician Orientation/Education
Ongoing
What is CDI?
Goal Approach Results
The goal of the CDI A clinical approach to improve • To secure documentation that
Program is to serve as a physician/hospital accurately represents severity
resource to the documentation: of illness and risk of
physician to assist in the mortality of your patients to
Concurrent medical record
most accurate, improve …
reviews of hospital/physician
concurrent, compliant • Physician & Hospital
documentation are done by
documentation of Profiling
RNs/Coders (Clinical
condition and treatment. • Patient Safety/Improved
Documentation Specialists).
Patient Care (Concurrent)
• Quality Core Measure
Adherence
• Compliant
Reimbursement
• Complete/Accurate
Contributions to Data
Resources
• Increase Odds of a
“Successful”
RAC/Commercial Audits
• ICD-10 Readiness

Copyright 2011 Trinity Health - Novi, Michigan 2


Why should physicians care?

Your information is available worldwide through the internet websites

Sample websites:

www.RateMDs.com

www.DrScore.com

www.HealthGrades.com
3
www.vitals.com
How are physicians profiled?

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How are physicians profiled?

Physician profiles
should accurately
reflect their
patient’s SOI and
ROM, confirming
the excellent care
they provide…

What does your


profile say?

Copyright 2011 Trinity Health - Novi, Michigan 5


What’s so important about my CMI?

Average
CMI LOS
Dr. Smith 1.8 6 days

Dr. Jones 2.5 6 days

Lower CMI with SAME length of stay?

Which surgeon pops up in the Federal database as “inefficient”?


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What’s so important about my CMI?

Total Number
CMI Of Case
Fatalities 2010
Dr. Smith 1.8 5

Dr. Jones 2.5 5

Lower CMI and Same mortality rate?

Who profiles as the better physician?

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What is the Documentation Clarification process?

Copyright 2011 Trinity Health - Novi, Michigan 8


The Importance of Clear and Complete Documentation
Sign/Symptom Sepsis
Vital Sign Lab Value Symptom
No Dx

• “75y/o chronic lunger w fever, leukocytosis, SOB


with hypoxia and altered mental status.”
Lab Value Clinical Finding

204 RESPIRATORY SIGNS & SYMPTOMS 0.67

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

hospitalization. Now presents with probable


sepsis, with acute septic encephalopathy as well.”
Principal Dx MCC
SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+
871 1.919
HOURS W MCC
Copyright 2011 Trinity Health - Novi, Michigan 9
What does it look like?
• Documentation Clarification (Brief) (TH)

• Patient: Sick, patient A MRN: (BIA)-0000001 FIN: 000000000-0001
• Age: 100 years Sex: Male DOB: 1/1/1911
• Associated Diagnoses: None
• Author: Ziblis, Cynthia

• Communication
• Documentation Clarification
• Prepared by: Clinical Documentation Specialist: Ziblis, Cynthia, telephone extension: 7163.
• Attending Physician: Special, physician
• Patient Room: 3226.
• Admission Date: 7/8/2011.
• Request for Clarification
• Physician:
• Special, physician
• Query:
• The medical record reflects a low Hgb and HCT treated with transfusions. In your medical opinion what is the corresponding diagnosis?

• Acute blood loss anemia
• Fe deficient anemia
• or
• Other explanation of clinical findings
• Unable to determine (no explanation for clinical findings)

• 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

Cynthia Ziblis, Robin O’Leary

RN CCDS RN CCDS

Ext 7163 Ext 7104


What should you remember about CDI?
1. We have tools to help you (and us)…Compliant Documentation Newsletter (emailed
bimonthly), information/“cheat sheet” cards, and more
• Look up CDI Council on Trinity Health Nexus site
2. Please don’t ignore our clarifications – it is okay to disagree and educate us
3. Consistency is important – link the indicators to diagnosis and treatment until condition
is resolved or ruled out – and document through to the discharge summary
4. Use “acute” and “chronic” to identify the diagnosis
5. The discharge summary should include all diagnoses (medical and surgical) from entire
hospital encounter
6. Be specific: Coders are not permitted to base codes on lab reports, diagnostic
procedures and/or tests.
7. Tell the coder exactly what you mean:
  Hgb ≠ anemia
• If it’s anemia then what type?
–Infiltrate ≠ pneumonia
• If it’s pneumonia then what type?
–Urosepsis
• Really?-Should read “sepsis due to urinary source”
–Debridement
• Excisional or nonexcisional?

Copyright 2011 Trinity Health - Novi, Michigan 12


Documentation Affects Everything!
SOI/ROM

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

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