Documentation that Serves a Purpose

by Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, C-CDAM

In drafting a physician open door forum presentation on the role of complete and accurate clinical documentation as an effective strategy for preparation in value based performance measurement and the Merit Based Incentive Payment System, I came across a PowerPoint slide I have referred to in the past. Dr. William Osler, a highly accomplished physician in his time, the Father of Modern Medicine, the creator of the of residency programs as they exist today as one of the founding fathers of John Hopkins Medical School, has coined many practical provocative sayings. The following really hits home as a CDI professional who continually advocates for a unique vision of CDI that incorporates methodologies and processes to affect positive sustainable change in physician practice patterns of documentation standing for communication of patient care versus primary focus upon reimbursement associated activities and physician education.

• The physician treats the disease; the great physician describes, shows, tells and treats the patient who has the disease. Sir William Osler (1849-1919)

The CDI profession can truly collaborate and partner with physicians in preparation for MIPS and other value based healthcare delivery models by acquiring the core knowledge and skill sets representing evidence based concepts of documentation improvement. We certainly can assist physicians in their quest to describe, show and tell the patient who has a disease, complemented by our proven ability to promote and achieve documentation of clinical specificity including increasingly important elements of clinical validation.

So, what is the makeup for the physician to show, describe and tell the clinical facts, information and clinical context associated with hospital level of care? The following fundamental components of documentation are essential in the scheme of patient care:

H & P

H & Ps should adhere to the following outlines

• Chief Complaint setting the stage for nature of presenting problem
• History of Present Illness with an emphasis upon “present” vs. “past”
• Clinically relevant Past Family Social History and Review of Systems
• Physical exam congruent with the nature of the presenting problem and clinical judgment of the physician
• Medical decision-making correlating with the clinical information, facts of the case and accurate reflection of assimilation of information as documented in the record including results of diagnostic workup treatment in the Emergency Department as well as the available test results and clinicals of the patient
• Clinical impression accurately reflecting and reporting provisional and definitive diagnoses that can be traced back to the physician work performed and clinical picture as described, told and shown in the HPI
• Plan of care congruent with the assessment, matching up each order to the diagnosis(es) and/or symptoms

Progress Notes

• Progress notes should meet the following characteristics
• Factually correct
• Temporally relevant (no future tense references to procedures already done)
• Concise (no fluff; just a concise statement of the facts)
• Devoid of plagiarism
• Analytic- (reflects thoughtful analysis of patient’s diagnosis, status, and treatment options)
• Reflective of collaboration (acknowledges collaboration with house staff, nursing, and other consultants)

Discharge Summaries
Discharge Summaries should meet the following component parameter as required by the Joint Commission:

• Reason for hospitalization.
• Significant findings.
• Procedures and treatment provided.
• Patient’s discharge condition.
• Patient and family instructions (as appropriate).
• Attending physician’s signature.

Other recognized guidelines for discharge summaries as advocated by the Society of Hospital Medicine include the following:

• Reason for hospitalization including presenting problems that precipitated hospitalization
• Concise summary of diagnoses, primary and secondary, including any complications or co-morbidity factors
• Key findings and test results
• Hospital course, including significant findings
• Procedures performed, and treatment rendered
• Conditions at discharge including functional status and condition status as well as limitations
• Discharge destination and rationale if not obvious
• Patients/Family instructions for continued care and/or follow-up

Closing Remarks

I encourage and challenge all CDI specialists to begin the journey in transitioning away from repetitive chart reviews in search of diagnoses and clinical validation only to bringing into the fold the quality and completeness of clinical documentation as outlined above. We must recognize the need and capitalize upon the opportunity to work collaboratively with our physician constituents to clearly, concisely, consistently and explicitly describe, show and tell the patient story in a manner that best communicates the quality focused cost effective patient centric efficiently guided patient care provided and achieved.

About the Author

Glenn Krauss is a longtime Revenue Cycle Professional with progressive hands one experience in all facets of the revenue cycle. He possesses a high energy level and passion for clinical documentation improvement initiatives that drive physician engagement in truly wanting to learn and acquire best practice standards of clinical documentation supporting communication of patient care.  He is the creator and founder of Core-CDI.com.