Documentation in the medical chart is important to ensure that severity of patient illness and case complexity is accurately reflected. Ambiguous language and inconsistencies between provider notes can lead to inaccurate coding, resulting in an imprecise reflection of work efforts by the medical team and a potential loss of revenue for the institution.
(1) To develop an educational relationship between physicians and the coding team to ensure accurate and complete documentation in the medical record, (2) to allow review and clarification of the medical record to occur concurrent with the patient stay.
A clinical documentation improvement (CDI) program was implemented at our institution in 2010. Hospitalists care for 70% of admitted medicine patients and piloted the program. Prior to the program, there was no formalized, routine education or process for documentation clarification. Coders paged physicians to respond to issues post–patient discharge. Physician response was sporadic and often delayed. The newly implemented CDI program consisted of (1) assessment of the baseline documentation practices, (2) formalized lecture series based on findings of hospitalist practices and best practices for similar institutions, (3) hiring of 5 clinical documentation specialists (CDS) to do real‐time chart reviews and round on units to interact with hospitalists, (4) creation of an electronic query system for coders to ask clinical questions in real time, and (5) a weekly electronic notification of provider compliance and financial implications of modifications. Individual query response rates were sent weekly and included with hospitalists' annual feedback session with the chief hospitalist. Since the CDI's inception, the number of charts queried each month has increased by as much as 300%. In 2011, 711 hospitalist charts were queried, with a 92% response rate, an average response time of 5 days, and a potential reimbursement benefit of $1,555,865. Through November 2012, the most recent data available, 1934 hospitalist charts were queried, with a response rate of 99% (compared with a 65% response rate for nonhospitalists), and an average response time of 3.5 days. The potential reimbursement benefit of the hospitalist charts was $3,676,582.
Instituting a comprehensive clinical documentation improvement program led to more accurate clinical documentation in the medical chart, with more rapid response times by hospitalist physicians. Having charts reviewed and clarification sought, concurrent with the admission, as opposed to postdischarge, may have contributed to the success of the program. Downstream effects include enhanced financial benefit to institution.
To cite this abstract:Rizk D, Nussbaum A, Cosner R, Mullings P. An Effective Strategy for Enhancing Clinical Documentation. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 172. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/an-effective-strategy-for-enhancing-clinical-documentation/. Accessed July 23, 2019.