Clinical Documentation Matters

Pull your medical staff into documentation compliance:  Audio & downloads available to CD Matters registrants

Program Description

It is essential to base your clinical documentation training on the objective, well-defined theory of high quality clinical documentation (HQCD).  The theory holds that high quality documentation meets seven criteria, all derived from official sources including the Medicare Conditions of Participation, the Joint Commission, the Office of the Inspector General’s Hospital Compliance Guidance and the American Health Information Management Association’s practice briefs. These criteria (legibility, timeliness, clarity, completeness, consistency, reliability and precision) are described in detail during this session. Documentation examples of each criteria are shared with participants.             

You will learn the value of using the criteria for HCQD as a structure that physicians can process in a more scientific manner than the approaches used in traditional clinical documentation training.  You will learn how to walk physicians through the criteria and application so they can apply the criteria to their own clinical documentation practices.

During a recent CDI Metrics webinar sponsored by DJ Iber and presented by Ruthann Russo and Barbara Hinkle-Azzara, the following question was asked.  Because it sparked much interest from the over 150 attendees, we wanted to share this question and answer with our readers at CD Matters.

Question:  How do you differentiate between a no response and a disagree when following up? Rarely do I have a physician state, “I disagree with the question.” It is more common that the diagnosis seems to go in a different direction after my query. Is this an example of a disagree? For instance, with congestive heart failure (CHF), I query for specificity based on preliminary findings, but in the following days, there is no further mention of CHF as the diagnosis was determined.

In stage four, the use of computerized evidence-based medicine protocols presents additional opportunity for value-added synergies between the electronic medical record (EMR) implementation and clinical documentation improvement (CDI).  According to the Healthcare Information and Management Systems Society (HIMSS), stage four EMR transformation means the organization has implemented a computerized physician order entry (CPOE) for use by any clinician along with the second level of clinical decision support capabilities related to evidence-based medicine protocols. If one patient service area has implemented CPOE and completed the previous stages, then this stage has been achieved.