Another Biggest CDI Challenge winner, Stacey Forgensi, is announced. You can read Stacey's complete story on the home page of the CD Matters website. I just wanted to re-emphasize here in the blog why I chose Stacey's story. Stacey's is a story of true challenge in employing a multi-tiered strategy to obtain accountability from the physicians for their clinical documentation practices. Her's is a bittersweet, yet familiar ending, with surgeons choosing to abstain and family medicine physicians all in favor. Here are some of the many strategies Stacey used to obtain accountability, taken directly from her story:
"I tracked and trended queries, response, agree, and no response rates. Weekly presentations were conducted after teaching rounds, and new residents were mandated to attend by the vice president of trauma and surgical services and the chief of surgery. A scenario was given at the end of the presentation, and residents were asked to write an admit note based on the scenario. Many tools were instituted to help with documentation. Tabbed dividers with documentation tips were placed in the front of every inpatient chart. Excisional debridement posters were hung throughout the hospital in pertinent places, such as surgery on-call rooms, conference rooms, operating rooms, and dictation areas. A debridement procedure note was created as an electronic form requesting all the pertinent information a coder would need. Bookmarks were distributed with the top ten queried diagnoses, and on the back were tips on what to include in history and physicals, daily progress notes, and discharge summaries. Pre-printed daily progress notes were created that included common surgical diagnoses using a checkbox format. Physician newsletters were published monthly with documentation guidelines, coding rules, and a “diagnosis of the month” commonly documented incorrectly."
By my count, Stacey describes at least 10 different strategies in the paragraph above. One take-away from Stacey's story may be that multiple strategies can have an impact - at least with medicine physicians. It is unclear and uncertain to what degree all of this "stage setting" may have played in having the family practice physicians come forward with requests for help in improving their documentation. But it's easy for the non-physician administrators to forget that the concept of a a high quality clinical docmentation practice was never addressed with physicians during their training.....and many hospitals may have expected a 10 minute powerpoint presentation to "do the trick". But, if indeed we want physicians to account for their documentation practices, then, like Stacey, we need to emphasize the importance of documentation by addressing it in every possible venue. Thanks Stacey!
