Clinical Documentation Matters

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.

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.