What’s Your Position on the Primary Purpose of Clinical Documentation?

Effective physician communication of patient care serves a wide array of different purposes in the overall scheme of healthcare delivery, the most important consisting of facilitating fully informed coordinated patient focused quality outcomes-based cost-effective care for the patient. The American College of Physicians sums it up nicely when it comes to the primary purpose of clinical documentation in an article published in the Annals of Internal Medicine position paper titled Clinical Documentation in the 21st Century: Executive Summary of Policy Position Paper:

• The primary goal of EHR-generated documentation should be concise, history-rich notes that reflect the information gathered and are used to develop an impression, a diagnostic and/or treatment plan, and recommended follow-up.
• The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication.
• The clinical record should include the patient’s story in as much detail as is required to retell the story.

As CDI specialists, what should our focus be in regards to chart review and enhancing the value and completeness of the physician documentation? First and foremost, we should recognize and treat our duties and responsibilities as a clinical documentation integrity specialists in the fashion of “facilitators in communication of patient care.” This facilitation entails incorporating a holistic approach to reviewing the record, identifying keep documentation gaps the detract from the accurate and complete describing, telling, depicting and depicting the true patient story in enough detail that an outside reader can quickly understand the patient story and identify the patient in the story. Effective documentation easily allows the next hospitalist physician or consultant called in on the case to either assume care where the first hospitalist left off or the consultant to quickly understand the patient story, the reason for the consult and the ordering physician’s clinical thoughts and rationale. Rather than searching for clinical clues for a diagnosis that has been overlooked or a diagnosis that has been documented lacking clinical specificity, the CDI specialists should interpreting the record identifying lapses in documentation of the patient’s chief complaint, History of Present Illness. Physical Exam, Assessment and Plan of Care.

The questions we should be asking ourselves as part of the chart review process are…

1) Does the documentation clearly report and depict the patient’s true severity of illness, how sick does the patient look as recorded in the HPI;

2) Is the physical exam congruent with the HPI and nature of presenting problem-what was wrong with the patient, what did the patient look like and how did it manifest as recorded in the ED documentation as well as the HPI;

3) Is the clinical impression/assessment congruent with the HPI and can I trace back every acute diagnosis recorded in the assessment back to the signs and symptoms as recorded in the HPI; and

4) Is the plan of care rational and congruent with the assessment, can I associate physician orders back to a definitive diagnosis or provisional diagnosis in the assessment.

I characterize clinical documentation in the History and Physical as sufficient and adequate if I am able to affirmatively check off the following in the patient story as told by the physician:

• How did the patient clinically present, what was wrong with the patient and how did it manifest?
• What treatment was provided in the Emergency Department and what was the patient’s response clinically?
• What did the patient look like clinically at the conclusion of ED level of care when a decision was made by the attending physician to hospitalize the patient?
• Does the History of Present Illness clearly report and reflect the severity of the patient’s presentation in terms of signs and symptoms versus a recapitulation of the patient’s past illness?
• Where is the patient now as reported in the H & P?
• What is the physician thinking and why-clinical rationale and thought processes documented?
• Where is the physician going in the plan of care and why?
• What is the physician going to do when results of diagnostic workup are available-what plans does the physician plan on initiating when results are available?

If any of the answer to any of these questions are not able to be affirmed, then the documentation and communication of patient care can be deemed to be insufficient and incomplete. This signifies opportunities for the clinical documentation improvement specialists to reach out to the physician and address any identified insufficiencies with the physician in a positive and collegial fashion to the mutual benefit of the patient and physician. Notice the stark contrast of a holistic chart review process as described above when compared to the standard approach to chart review where the main focus is upon identifying and securing diagnoses impacting reimbursement and/or or quality measurements without enhancing the completeness and effectiveness of the reporting of the clinical information, clinical facts and context.

My closing thought…

CDI are Facilitators in Communication of Patient Care.

NOT strictly reimbursement bounty hunters searching for diagnosis to jack up the Case-Mix Index and reimbursement!