Editor's note: There are a number of ways to get information into the hands of your facility's physicians. The following list offers several suggestions on how to train and engage your medical staff. This article was adapted from the October issue of CDI Journal, a quarterly publication for members of the Association of Clinical Documentation Improvement Specialists (ACDIS). Additional information is available at www.acdis.org.
Legible.Complete.Dated, timed, signed, and authenticated.That's what section 482.24 of the Medicare Conditions of Participation requires of your medical records.
I promised in a previous “Standards of the month”column that I would address Joint Commission standard MM.04.01.01 (orders for medication are clear and accurate), as this standard made it onto the 2010 top 10 list of standards with which hospitals were noncompliant. In fact, 30% of hospitals failed to comply with it.
Many organizations develop physician documentation tip sheets based on the clinical topics appropriate to their specific facility. Some handouts are a simple piece of paper developed by a clinical documentation improvement team, whereas others are laminated, elaborately formatted cards from consulting companies distributed as part of the initial implementation program. Several samples donated by members of the Association of Clinical Documentation Improvement Specialists (ACDIS) are available on its website at www.hcpro.com/acdis. (See p. 11 for a sample.)
Many of the nation’s hospitals now have clinical documentation improvement (CDI), management, or integrity programs. They are designed to help physicians improve the documentation of diagnostic or procedural information in inpatient medical records so that the documentation meets the needs of the coding process. There are good things that can come out of these programs, but there can also be bad things.
As the Patient Protection and Affordable Care Act implementation progresses, the quality and outcomes of care face increasing public scrutiny. Policymakers will determine our complication rates and publicize them on the Internet, influencing public perception of our competencies and quality. Don’t believe me? Read in the Atlanta Journal-Constitution about some Georgia hospitals’ “high” pneumonia, heart failure, and myocardial infarction mortality (http://tinyurl.com/GA-mortality). See your own cost efficiency and quality profile on United Healthcare’s website (www.uhc.com) under the “Find a Physician” tab. Where is information to make these determinations obtained? It’s from ICD-9-CM codes assigned by our hospitals based upon documentation. Consequently, we have a vested interest in ensuring that complication codes are submitted accurately.
