Clinical Documentation in the Inpatient Setting - PowerPoint PPT Presentation

Loading...

PPT – Clinical Documentation in the Inpatient Setting PowerPoint presentation | free to download - id: 6577ba-NTY1N



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Clinical Documentation in the Inpatient Setting

Description:

Clinical Documentation in the Inpatient Setting Outline Documentation For Compliance Rules of the Road Clinical Documentation Improvement Program (CDIP) Documentation ... – PowerPoint PPT presentation

Number of Views:126
Avg rating:3.0/5.0
Slides: 31
Provided by: hay51
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Clinical Documentation in the Inpatient Setting


1
Clinical Documentation in the Inpatient Setting
2
Outline
  • Documentation For Compliance
  • Rules of the Road
  • Clinical Documentation Improvement Program (CDIP)
  • Documentation Examples

3
Documentation For Compliance
4
HP Required Elements
  • Must be completed within 24 hours of admission or
    30 days prior to with update day of admission
  • Chief Complaint
  • History of Present Illness
  • Past Medical History
  • Medications
  • Allergies
  • Immunizations
  • Family Medical History
  • Social History
  • Substance Use
  • Review of Systems
  • Physical Examination
  • Labs X-ray Findings
  • Analysis of Admitting Problems
  • Problem List
  • Plan
  • Consultations

5
Common Issues with HP
  • Handwritten HPs
  • Document not dated/signed
  • Incomplete Reports
  • Missing physical evaluation, past medical
    history, and plan
  • Forget to update the HP at the time of admission
    if documented within past 30 days

6
Discharge Summary Elements
  • Due the Day of Discharge
  • Name of attending physician
  • Patient Name
  • Admit Date
  • Discharge Date
  • Principal Diagnosis
  • Principal Procedure
  • Hospital Course
  • Condition on Discharge
  • Activities
  • Diet
  • Follow-up Appointments
  • Medications
  • Copies of Summary sent to (PCP, Referring
    Physician, Consultants)

7
Common Issues with Discharge Summary
  • Common Missed Elements
  • Admit Date
  • Condition on Discharge
  • Activities
  • Diet

8
Brief Post Op Note Elements
  • Name of surgeon, proceduralist, and assistants
  • Procedure performed and a description of the
    procedure
  • Findings
  • Estimated blood loss
  • Specimen(s) removed
  • Postoperative diagnosis

RC.02.01.03
9
Common Issues with Brief Post Op Note
  • Findings left blank
  • Doctors must amend or attest for anything done by
    medical student
  • All paper brief post op notes must be signed,
    dated, and timed by doctor

10
Contact Information
  • Linda McNeil, Assistant Director of MIS
  • 322-3857
  • Adult Medical Records Hub
  • 322-2205 and 343-3060
  • History Physical contact information
  • Ben Giles 343-1659
  • Discharge Summary contact information
  • Alisa Maloney 343-4449
  • Brief Post Op Note contact information
  • Adult Medical Records Hub
  • 322-2205 and 343-3060
  • Linda McNeil, Assistant Director of MIS
  • 322-3857
  • VCH Medical Records Hub
  • 936-5278
  • VCH History Physical contact information
  • Amaris Scott 343-8510
  • VCH Discharge Summary contact information
  • Amaris Scott 343-8510
  • VCH Brief Post Op Note contact information
  • VCH Medical Records Hub
  • 936-5278

11
Rules of the Road
12
The Purpose of the Medical Record is
  • to serve as a basis for planning patient care and
    for continuity in the evaluation of the patient's
    condition and treatment
  • to furnish documentary evidence of the patient's
    medical evaluation, treatment, and change in
    condition during the hospital stay, during an
    ambulatory care or emergency visit to the
    hospital
  • to document communication between the responsible
    practitioner and other health professionals who
    contribute to the patient's care
  • to assist in protecting the legal interest of the
    patient, the hospital and the responsible
    practitioner
  • to document for the purposes of third party
    payment that a test or procedure is medically
    necessary, has been ordered, has been done, and a
    result (in the case of tests) is in the chart.

13
TDKD
  • The history, examination and decision making
    process for diagnosis and treatment are the key
    elements of a providers note for each patient
    encounter. Those key elements should be
    concisely described in the note using the
    following points (referred to as TDKD) concisely
  • What the author Thought about each issue
  • What the author Did about each issue
  • What others need to Know about each issue
  • What others need to Do about each issue

14
Clinical Documentation Improvement Program (CDIP)
15
What Is A Clinical Documentation Improvement
(CDI) Program ?
  • A CDI program is designed to improve inpatient
    record documentation by establishing a
    coordinated, systemic process utilizing a
    concurrent review team to strengthen
    communication between caregivers, physicians and
    the coding professionals
  • Ensure that the clinical documentation in the
    patient record accurately reflects the patients
    principal diagnosis (reason for admission)
  • Secondary diagnoses (co morbid conditions) are
    documented
  • Capture procedures performed
  • Provide an accurate picture of the patients
    acuity, severity of illness, and expected chance
    of mortality for this particular hospitalization

16
Why Implement A Clinical Documentation
Improvement Program?
  • New laws and regulations, ongoing federal
    reforms, and payer initiatives are increasingly
    aligning quality outcomes with financial
    incentives and reimbursement
  • Medicare and many third-party insurers now
    consider patient severity of illness and
    post-admission complications when calculating
    payment
  • At the same time, accurate capture of patient
    acuity and risk of mortality impacts your
    hospitals case mix index (CMI), which influences
    quality outcomes and hospital performance reports
    made available to consumers

17
Secondary Conditions Are
  • additional conditions that affect patient care in
    terms of requiring clinical evaluation,
    therapeutic treatment, diagnostic procedures,
    extend the length of stay, or increase nursing
    care and/or monitoring resource utilization
  • In addition these conditions also affect the
    expected mortality assigned to each discharge
  • These conditions are referred to as major co
    morbid conditions(MCC) or co morbid conditions
    (CC)

- additional conditions (secondary
18
Do Severity and Risk Adjustment Really Make a
Difference?
  PRINCIPAL DIAGNOSIS Procedure Subarachnoid Hemorrhage with Repair of Aneurysm PRINCIPAL DIAGNOSIS Procedure Subarachnoid Hemorrhage with Repair of Aneurysm  
  Original Documentation Additional Documentation  
Secondary Diagnosis Occlusion Specf Artery W Infarction Aphasia COPD ABLA Repair of Aneurysm Vent gt 96 hours Occlusion Specf Artery W Infarction Aphasia COPD ABLA Coma Acute Respiratory Failure Repair of Aneurysm Vent gt 96 hours  
APR DRG 21 Craniotomy Except for Trauma 21 Craniotomy Except for Trauma  
APR DRG Severity of Illness 3 Major (Weight 4.7570) 4 Extreme (Weight 8.6888)  
APR DRG Risk of Mortality 1 Minor 4 Extreme  
APR DRG Risk of Mortality 0.0064. 0.4438  
       
19
Impact of MCCs and CCs on a Neurosurgery DRG
MS-DRG 20 Intracranial Vascular Procedures With A
PDX of Hemorrhagic (with a major co morbid
condition) Coma -Weight 7.7073
V24 DRG
Intracranial Vascular Procedures DRG 528 Weight
7.0543
MS-DRG 21 Intracranial Vascular Procedures With A
PDX of Hemorrhagic (with a co morbid condition)
Cachexia -Weight 6.7021
MS-DRG 22 Intracranial Vascular Procedures With A
PDX of Hemorrhagic (without a major co morbid
condition or co morbid condition) -Weight
5.6085
20
Do Document
  • Significant acute diseases
  • Acute exacerbation of significant chronic
    diseases
  • Advanced or end stage chronic diseases
  • Chronic diseases associated with a systemic
    physiologic decompensation and extensive debility

21
Definitions Mortality O/E
  • Observed mortality actual inpatient deaths
  • Expected mortality those inpatients who are
    expected to die during the hospitalization based
    on the clinical documentation in the medical
    record
  • OE Ratio The number of observed deaths divided
    by expected mortalities

22
(No Transcript)
23
Concurrent Review Process
  • The CDC staff will query when they suspect a
    complication or co morbidity exists but has not
    been documented or specificity is required. The
    primary mode of contact is in email form.
    Occasionally the queries may be verbal.
  • The CDC staff enters the data into our tracking
    software. A report is then generated monthly that
    gives the percent of the time that a particular
    service and/or clinician responded to the query
    and what particular diagnosis the CDC was looking
    for.
  • This report is sent to the Chief, Chair,
    department head or designee to review and report
    out to the faculty. The queries are tracked as
    being Agree (with subsequent documentation of
    the diagnosis in the medical record), Disagree
    meaning that the clinician didnt agree with the
    query, unknown meaning the clinician was asked
    but doesnt know, and No response.
  • We ask that if the provider disagrees with the
    query or believes that the query needs to go to
    another provider that they let us know
    immediately so that we can contact the
    appropriate physician with our query. Please do
    not ignore the query

24
Documentation Examples
25
Documentation of Heart Failure requires acuity,
side, systolic/diastolic and etiology when known.
  • Acute systolic heart failure
  • Acute on chronic systolic heart failure
  • Acute diastolic heart failure
  • Acute on chronic diastolic heart failure
  • Acute combined systolic and diastolic heart
    failure
  • Acute on chronic combined systolic and diastolic
    heart failure
  • Left heart failure
  • Unspecified systolic heart failure
  • Chronic systolic heart failure
  • Unspecified diastolic heart failure
  • Chronic diastolic heart failure
  • Unspecified combined systolic and diastolic heart
    failure
  • Chronic combined systolic and diastolic heart
    failure

Acuity acute, chronic, or combined Side
right, left, or combined
Acuity acute, chronic, combined Side
right, left, combined
26
(No Transcript)
27
History Physical
  • Assessment and Plan
  • Ms. X is a 73 year old female with h/o HTN, COPD,
    Dementia and brain and lung cancer presenting w/
    2 days of dyspnea and wheezing. No signs or
    symptoms suggestive of pneumonia. Suspect
    COPD/emphysema exacerbation.

28
FINAL NOTE AND DISCHARGE SUMMARY
  • Synopsis/Reason for Hospitalization/Principle
    Diagnosis  Synopsis Ms. X is a 73 year old
    female with h/o HTN, COPD, Dementia and brain and
    lung cancer presenting w/ 2 days of dyspnea and
    wheezing. No signs or symptoms suggestive of
    pneumonia. Suspect COPD/emphysema exacerbation.
    CXR showed bibasilar opacities. Ready for
    discharge home with family today. Diagnosis/Hospit
    al Course/Treatment   COPD exacerbation
    resolved - continue supplemental oxygen -
    continue nebulizers - prednisone 40mg daily,
    tapering - Resolved with treatment Community-acqu
    ired pneumonia - CXR showed increased bibasilar
    opacities - started on oral Levaquin, will finish
    course at home Disposition - resides at home
    with family - SW aware - ready for discharge home
    with family today - spoke with family in room
    before discharge and updated on medication
    changes and new abx, very agreeable and will have
    patient follow-up with PCP

29
Example
  • PHYSICAL EXAMINATION GENERAL Well-developed,
    well-nourished man who appears comfortable, and
    in no apparent distress.
  • VITALS Temp 96.0 deg FP 94 RR 18 BP 128/93
    Height 72.1 in (10/22/09) Weight 108.91 lb
    (11/17/09) O2 sat 100 on room air
  • Cachetic man lying in bed in NAD, has just
    vomitted small amount of non-bloody, non-bilious
    emesis course
  • BS bilaterally rrr, 0 m/r/g
  • abdomen soft, mildly distended. no peritonitis

Pt. weight 108, height 61- has esophageal
cancer The conflicting documentation was in the
same progress note
30
Questions?
  • Stephanie.A.Hays_at_Vanderbilt.edu
  • 322-0663
About PowerShow.com