clinical documentation improvement best practices

Making use of technology, to allow patients to review their medical records on an online portal can and will help the facility to improve the accuracy of its documentation. According to the American College of Physicians, practices should define guidelines based on “consensus-driven professional standards unique to individual specialties.”. Her department provides coding and documentation education and training for physicians and clinical support staff. We are looking for thought leaders to contribute content to AAPC’s Knowledge Center. Clinical Documentation Improvement (CDI) Basics You can make a copy of your quiz result and email it to a recipient by pressing the Alt and PrtScr buttons at the same time while viewing your score. The advisor needs to be enthusiastic about the program, complete knowledge of best documentation practices and a good role model. By encouraging discussion and active learning, this interactive event prepares ... • Clinical Documentation Improvement: Quality Measures and Make auto-generated notes distinct: Electronic health records (EHRs) are often limited with the use of “click and point” or auto-generated scripts to populate the patient record. From a clinical documentation perspective, an initial presentation of a newly developed, undefined root cause evaluation may warrant a comprehensive review of potential findings. Similarly, if aspects of a patient’s medical history play a role in the physician’s decision-making, a summary of that history and how it affects treatment options should be included. Collaboration is important to quality care and should not be reimbursement-driven, per se, but should stress the requirements for coding (i.e., capturing necessary details). Coded data is derived from clinical documentation provided during the patient encounter. Providers should understand how their clinical documentation translates into data that is used for a variety of purposes. This version is made available for historical purposes only. As a contributor you will produce quality content for the business of healthcare, taking the Knowledge Center forward with your knowhow and expertise. Collaborate efficiently: Ideally, each provider or specialist should provide an interval or pertinent history as it pertains to the portion of care they are providing. This improves overall patient care, as well as enhances risk management from a patient safety perspective, with fewer return visits to the office, shorter hospital stays, and increased quality scores. Capture new developments and pertinent findings: Providers in the office setting tend to create comprehensive “all normal” examination templates. Based on the chief complaint/clinical exam findings, establish specific treatment goals for each patient which are . 3. With detailed, accurate documentation, clinical analytics can assist in improving the decision-making process and help catch the development of complications before they begin. For example, auditing and coding departments may provide examples and education on how to maximize coding, billing, etc., through careful documentation. Join AAPC’s Author Panel - Be Recognized, Best Practices to Achieve Clinical Documentation Improvement, Focus on Coding 3 Common Pediatric Eye Conditions, Break the Cycle of Poor Physician Documentation, Achieving Clinical Documentation Improvement, 5 Ways to Improve CDI and Coder Collaboration, Documenting an all normal exam does not add any benefit to the care provided, especially when not necessary; and. A good way to reduce the practice’s reliance on vendors and third party trainers is to appoint a physician advisor/champion to spearhead the CDI program. Crews serves as a member of ENT and Allergy Associates’, LLP senior leadership team as the director of regulatory affairs, providing oversight of their Corporate Compliance Program. The healthcare system is adapting as quickly as possible to the COVID-19 pandemic. Astara N. Crews, MJ, BS, CHC, CPC, has over 20 years of experience in coding, auditing, compliance, and corporate governance. Check that E/M leveling narrates the true nature of the visit: Typical EHRs use boilerplate documentation templates with general canned statements geared toward hitting the documentation requirements for an evaluation and management (E/M) level four office visit, regardless of the nature of the presenting problem. Your staff may be familiar with documentation standards, but in this rapidly changing healthcare environment, it is important that they upgrade themselves regularly. Using such tools may result in “generic” patient records; individual visit notes may be indistinct from visit to visit (or even from patient to patient). Even one or two lines from the provider add detail and integrity to the note by answering all-important questions such as “How is this note unique?” or “What is unique to this patient at this visit?”. Unlike a traditional clinical documentation improvement specialist, the documentation quality manager is responsible for improving the technical component of documentation and coding. As it is, according to the requirements of Stage 2 Meaningful Use, allowing patients access to their medical records is mandatory – why wait to implement the same. Such a awesome post catch my eyes & pulled me up to learn more about CDI, waiting for future posts. Clinical documentation improvement (CDI) is a process that continually seeks to answer, “How best can we maximize the integrity of the medical record?” Although the goal of CDI is always the same — to provide a complete and accurate picture of a patient’s medical condition(s) and the care they receive — the means to achieve that goal are often specific to the setting (e.g., office versus facility). Identify missing charges to help optimize revenue and reduce the impact of negative cash flow. The purpose of this Practice Brief is to describe documentation best practices and serve as a resource in effective and efficient clinical documentation practices without having a negative impact on patient care. There are many tools and publications to assist providers in improving their clinical documentation such as AAPC’s auditing software and services and Healthicity Healthcare Auditing Services. The most important step to clinical documentation improvement is to create guidelines that match the best practices and industry standards. Quite often historical clinical information is “pulled forward” to the current encounter, and the conditions present at the initial onset of the patient’s presentation to the facility no longer exist, yet the conditions or diagnoses remain in the active problem list. To really benefit from the program, it is important that the following performance metrics are monitored. In summary, a clinical documentation improvement program is a comprehensive, multi-disciplinary effort that includes the medical staff, clinical documentation specialists, inpatient coders, and CDI physician advisors. Clinical documentation improvement (CDI) programs have evolved from being an informal part of the process to becoming the backbone of the facilities financial viability. The ALJ relies on the testimony of witnesses and the documentation from the survey in making a decision. Best practices require that a CDI physician advisor, often a hospitalist, support the CDI program. Create a culture that values data accuracy and implement educational opportunities that provide employees with the skills to operate a high performing clinical documentation improvement program. “The model has been to allow more customization in terms of documentation templates and less standardization around what are the best practices for a particular clinical … The aim is to provide clarity and brevity while keeping the needs of other readers in mind. Editor’s Note: This Practice Brief has been updated. In the facility setting, collaboration is both more readily available and vital to ongoing success. For example, if the physician must consider co-morbidities when deciding a course of treatment, the existence and status of those co-morbidities should be noted in the documentation. 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