Clinical documentation improvement spans the entire continuum of care from the time the patient presents to the Emergency Department or is direct admitted to the hospital until the time of patient discharge and the completion of the discharge summary. The CDI specialist’s role in enhancing the quality, completeness and effectiveness of clinical documentation is to recognize and treat the record as a communication tool as opposed to a reimbursement tool. Today’s present model of CDI incorporates and centers upon reimbursement as the primary outcome in the achievement of success of any CDI initiative. Unfortunately, the capability of the CDI profession to positively impact and capitalize upon the opportunity to assist the physician in accurately communicating and reflecting the actual care provided is not realized with this unrelenting focus upon reimbursement. Who really loses out is the patient who is totally dependent upon the physician and other ancillary care givers to accurately record and communicate the care rendered and response to clinical management and treatment from a continuity of care, quality and cost effectiveness perspective. Physicians are increasingly becoming tied to the concept of financial stewardship and the financial welfare of the patient, expected to consider the fiscal responsibility of the patient as a subset of care ordered and/or provided.

Focusing Upon Communication of Patient Care

Communication of patient care assumes a wide variety of meanings depending upon one’s individual framework and definition. Just the same, the fundamental basis of communication of patient care includes understanding, telling, showing and describing the patient story in enough detail for the next physician to assume care seamlessly where the first physician left off. Understanding and telling the patient sufficiently does not require the physician to devote more energy and time to authoring longer more detailed notes. Sufficient documentation equates to more clear, concise consistent and more effective notes. When it comes to medical record documentation, more is not better, better is better!

CDI can be a successful change agent for promoting documentation excellence, serving as the beacon much like a lighthouse in the New England on a stormy night. A logical starting point for CDI to champion complete accurate and effective documentation that best tells the patient story is to partner with the case manager in the Emergency Department who performs utilization review on those patient encounters with potential for hospitalization. Collaborate with the case manager in defining, educating, identifying what constitutes the standard of documentation that adequately conveys the clinical scenario, the severity of illness and nature of presenting problem, provisional and definitive diagnoses, and clinical judgment, medical decision making and thought processes utilized by the physician in recommending hospital level of care to the attending physician. The case manager in the Emergency Department uses commercial screening criteria to guide the physician in determining the appropriateness of hospitalization and the establishment of medical necessity. Screening criteria is just that, screening criteria that is designed and intended to be used as a guide for determining appropriateness of admission to the hospital. Screening criteria must be accompanied by adequate documentation incorporating detailed succinct clinical facts, clinical information and facts of the case clearly supporting admission decisions. Screening criteria cannot be used in and of itself without this supporting documentation that communicates patient care. Continual feedback and instruction must be provided to the Emergency Department in as real time as possible. A standard message regarding documentation effectiveness and telling of the patient story must be communicated to the ED physicians, consistently provided an on ongoing basis. This message can be structured and delivered in such fashion to ultimately benefit the patient, particularly given third party payer’s current initiatives to deny Emergency Department patient care under the pretense of not meeting medical necessity for the patient seeking care in this forum. Effective documentation that tells the entire complete patient story is critical to the establishment of medical necessity for all healthcare provisions.

Complete Effective Documentation That Best Tells the Patient Story

What does complete effective documentation that best tells, describes, shows, and depicts the patient story look like? For one the documentation must be concise, logically flow, be organized and outlined in a clear intuitive fashion and even more importantly contain and represent the physician’s clinical judgment and medical decision making. The following format can be used to judge the adequacy of the documentation in communicating the clinical facts, clinical information and context associated with the care transpired and delivered in the Emergency Department:

· Where has the patient been?

· Where is the patient now?

· What are you thinking?

· Why are you thinking that?

· Where are you going and why?

· What did you find when you got there?

· What actions did you take?

· What actions are still needed and how long is it going to take?

· What is the clinicals stability of the patient after management in the ED that necessitates hospitalization?

Partnering with Case Management & Utilization Review

A forward-thinking CDI program that achieves sustainable improvement in communication of patient care, thereby driving down unnecessary self-inflicted avoidable medical necessity denials begins within the Emergency Department. CDI in the Emergency Department entails much more than solidifying and clarifying diagnoses as a segway for inpatient admission and inclusion in the History and Physical. CDI can positively impact the quality and completeness of the patient story communicated in the medical record through partnering, aligning and integrating with the case manager in the Emergency Department to insure the case manager has the necessary skill sets and understanding of documentation standards and principles that project and convey the true clinical acuity of the patient in such fashion that any outside reviewer can easily understand the nature of the patient’s present problem, workup completed, clinical stability or lack thereof, comorbid conditions impacting management and need for continued workup of the patient’s clinical condition(s) within the hospital, potential and definitive diagnoses and potential risk of untoward event without hospitalization. There is far more CDI can accomplish to impact and achieve sustainable documentation, capturing the necessary elements of clinical documentation in support of medical necessity that both the physician, case manager and utilization review staff require to insure cost effective, efficient quality focused patient centered care in the correct setting and level of care. In my next blog I will be outlining a closely aligned integrated utilization review CDI model that is achieving positive results as relates to producing documentation that best meets the medical necessity requirements inherent to the third party payer authorization process. Stay tuned as I strive to share my successes and positive experiences in