CDI Clinical Documentation Improvement (Impact on quality… Hassan... · (Impact on quality, revenue development and recovery) ©2017 AHIMA’s Intellectual Property. All rights

CDI–Clinical Documentation Improvement(Impact on quality, revenue development and

recovery)

©2017 AHIMA’s Intellectual Property. All rights reserved.

CDI–Clinical Documentation Improvement(Impact on quality, revenue development and

recovery)

Najla HassanCase Coordinator – Mafraq Hospital

OBJECTIVES

• Transition from manual documentation to Electronic ClinicalDocumentation

• What is Clinical Documentation

• Impact of clinical documentation on patient care provided

• Why clinical documentation has poor quality?

• Criteria for high quality clinical documentation.

• Impact of clinical documentation on reimbursement

• Why we should have clinical documentation improvement programs

©2017 AHIMA’s Intellectual Property. All rights reserved.2

• Transition from manual documentation to Electronic ClinicalDocumentation

• What is Clinical Documentation

• Impact of clinical documentation on patient care provided

• Why clinical documentation has poor quality?

• Criteria for high quality clinical documentation.

• Impact of clinical documentation on reimbursement

• Why we should have clinical documentation improvement programs

TRANSITION FROM MANUAL DOCUMENTATION TO

CLINICAL DOCUMENTATION


WHAT IS CLINICAL DOCUMENTATION?

• Clinical Documentation is any manual or electronic notation orrecording made by a physician or other healthcare clinician relatedto patient’s medical condition or treatment.

• Clinical Documentation is the foundation of every patient healthrecord.

• Healthcare organizations are the core, medical representatives fortheir patient’s protected health information.


• Clinical Documentation is any manual or electronic notation orrecording made by a physician or other healthcare clinician relatedto patient’s medical condition or treatment.

• Clinical Documentation is the foundation of every patient healthrecord.

• Healthcare organizations are the core, medical representatives fortheir patient’s protected health information.

IMPACT OF CLINICAL DOCUMENTATION ONPATIENT CARE PROVIDED

• Clinical Documentation reflects the quality of care, severity of illness,and treatment provided for each patient the organization treats.

• Conducting quality review of the documentation.

• Proper documentation of patients’ progress during their stay in thehospital led to better pain management, and improvedcommunication of clinical information between team members atend-of-shift hand-overs.


• Clinical Documentation reflects the quality of care, severity of illness,and treatment provided for each patient the organization treats.

• Conducting quality review of the documentation.

• Proper documentation of patients’ progress during their stay in thehospital led to better pain management, and improvedcommunication of clinical information between team members atend-of-shift hand-overs.

WHY CLINICAL DOCUMENTATION HAS POORQUALITY?

• Researchers and the peer reviewed academic literature reveals thelack of adequate documentation and identified the following reasonsfor poor quality clinical documentation:

1. Medical school and residency programs don’t teach clinicaldocumentation practices.

2. Physician’s clinical documentation importance is not priority for thehealthcare organizations and the information in the inpatient settingis complex

3. Multiple providers are needed when there are longer patient stays,resulting in additional clinical documentation with increasedinconsistency between provider documentation.

4. Unstructured and inconsistent processes for recording andcollection of information are prevalent. (Cascio et al.2005;Novitsky etal.2005)


• Researchers and the peer reviewed academic literature reveals thelack of adequate documentation and identified the following reasonsfor poor quality clinical documentation:

1. Medical school and residency programs don’t teach clinicaldocumentation practices.

2. Physician’s clinical documentation importance is not priority for thehealthcare organizations and the information in the inpatient settingis complex

3. Multiple providers are needed when there are longer patient stays,resulting in additional clinical documentation with increasedinconsistency between provider documentation.

4. Unstructured and inconsistent processes for recording andcollection of information are prevalent. (Cascio et al.2005;Novitsky etal.2005)

CRITERIA FOR HIGH QUALITY CLINICALDOCUMENTATION

• High-quality clinical documentation is essential andimportant although it needs to be enhanced andimproved within the healthcare communities.

• Seven criteria for high quality clinical documentationrequired to be in all entries in the patient record are:


• High-quality clinical documentation is essential andimportant although it needs to be enhanced andimproved within the healthcare communities.

• Seven criteria for high quality clinical documentationrequired to be in all entries in the patient record are:


1. LegibleClear enough to be read and easily deciphered



2. ReliableTrustworthy, safe, and yielding the same result when repeated.



3. PreciseAccurate, exact, strictly defined



4. CompleteHas the maximum content; thorough



5. ConsistentNot contradictory



6. ClearUnambiguous, intelligible, not vague



7. Timely• At the time of service• Essential for the best treatment of the patient


IMPACT OF CLINICAL DOCUMENTATION ONREIMBURSEMENT



WHY WE SHOULD HAVE CLINICALDOCUMENTATION IMPROVEMENT PROGRAMS

• Clinical Documentation Improvement ( CDI) is a process used in a variety ofsettings by employees who review clinical documentation and providefeedback to physicians regarding ambiguous information. The feedback isdesigned to fill in gaps in documentation so that clear and conciseinformation is available for code assignment, quality measures, and overallpatient care.

• Improve Clinical Documentation to reflect patient acuity through ClinicalDocumentation review where case coordinators review patient’s clinicaldocumentation for completeness, and ensure appropriateness of the DRGassigned which reflects severity of illness.


• Clinical Documentation Improvement ( CDI) is a process used in a variety ofsettings by employees who review clinical documentation and providefeedback to physicians regarding ambiguous information. The feedback isdesigned to fill in gaps in documentation so that clear and conciseinformation is available for code assignment, quality measures, and overallpatient care.

• Improve Clinical Documentation to reflect patient acuity through ClinicalDocumentation review where case coordinators review patient’s clinicaldocumentation for completeness, and ensure appropriateness of the DRGassigned which reflects severity of illness.


EXAMPLES OF CLINICAL DOCUMENTATIONIMPROVEMENT


EXAMPLES OF CLINICAL DOCUMENTATIONIMPROVEMENT






Before comprehensivedocumentation

Before comprehensivedocumentation


After comprehensivedocumentation

After comprehensivedocumentation



• To improve the Clinical Documentation quality Case Managementteam along with the coding team has been conducting presentationsto different specialties which showed good improvement in some ofthem

• 70 % the improvement in the documentation in plastic surgeryspecialty.

• More than 80% Improvement in specialties like Internal Medicine,Cardiology, Neonatology and General surgery.


• To improve the Clinical Documentation quality Case Managementteam along with the coding team has been conducting presentationsto different specialties which showed good improvement in some ofthem

• 70 % the improvement in the documentation in plastic surgeryspecialty.

• More than 80% Improvement in specialties like Internal Medicine,Cardiology, Neonatology and General surgery.


0.00%

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Denial Amount/Rate 2016


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Denial Amount/Rate 2017

Denied Amount DenialRate

CONCLUSION

• Accurate documentation of patient encounters is the foundation for tellingthe patient’s story, appropriate reimbursement, and quality reporting.

• Better documentation can have a significant positive impact on the qualitymeasures of Severity of Illness (SOI) and Risk of Mortality (ROM).

• Organizations need to develop and comply with comprehensive internalreporting policies and procedures that are consistent with official coding rulesand guidelines, reimbursement regulations and policies, and prohibitdocumentation practices that misrepresent the patient's medical conditions andtreatment provided.

• CDI programs may also have the collateral benefit of improving quality of carerendered.

• Physicians must be taught the concepts of CDI in order to understand the returnon investment of the program and the benefits to them.


• Accurate documentation of patient encounters is the foundation for tellingthe patient’s story, appropriate reimbursement, and quality reporting.

• Better documentation can have a significant positive impact on the qualitymeasures of Severity of Illness (SOI) and Risk of Mortality (ROM).

• Organizations need to develop and comply with comprehensive internalreporting policies and procedures that are consistent with official coding rulesand guidelines, reimbursement regulations and policies, and prohibitdocumentation practices that misrepresent the patient's medical conditions andtreatment provided.

• CDI programs may also have the collateral benefit of improving quality of carerendered.

• Physicians must be taught the concepts of CDI in order to understand the returnon investment of the program and the benefits to them.

CONCLUSION

• If you didn’t document it, it wasn’t done,…or

• If it isn’t documented, it did not happen,…or

• Just because it wasn't documented, doesn't mean itdidn't happen.

• If it is documented, it’s important to ask “is it alsocorrect?”


• If you didn’t document it, it wasn’t done,…or

• If it isn’t documented, it did not happen,…or

• Just because it wasn't documented, doesn't mean itdidn't happen.

• If it is documented, it’s important to ask “is it alsocorrect?”

References

• http://www.middleeasthealthmag.com/cgi-bin/index.cgi?http://www.middleeasthealthmag.com/jan2011/feature13.htm

• http://blogs.hcpro.com/acdis/2010/09/clinical-documentation-improvement-what-is-your-definition/

• http://www.ehrdocs.com/pdf/news/Best_Practices_for_Clinical_Documentation_%20Improvement.pdf

• http://bok.ahima.org/doc?oid=106669#.WeHpBpAUmAV• http://library.ahima.org/doc?oid=101609#.WeOgpZAUmAV


• http://www.middleeasthealthmag.com/cgi-bin/index.cgi?http://www.middleeasthealthmag.com/jan2011/feature13.htm

• http://blogs.hcpro.com/acdis/2010/09/clinical-documentation-improvement-what-is-your-definition/

• http://www.ehrdocs.com/pdf/news/Best_Practices_for_Clinical_Documentation_%20Improvement.pdf

• http://bok.ahima.org/doc?oid=106669#.WeHpBpAUmAV• http://library.ahima.org/doc?oid=101609#.WeOgpZAUmAV



Thank You!


Thank You!

Documents

CDI Clinical Documentation Improvement (Impact on quality… Hassan... · (Impact on quality, revenue development and recovery) ©2017 AHIMA’s Intellectual Property. All rights