Proper Documentation is Critical to Our Modern Healthcare System

Proper documentation is indeed critical to our modern healthcare system. The accuracy and completeness of clinical documentation that translates into ICD-10 codes utilized in many distinct roles including quality and outcomes reporting, measures of efficiencies and effectiveness of care, and calculation and determination of value is critical to the entire healthcare delivery model. Clinical documentation improvement programs are purported to “improve” the quality and effectiveness of physician documentation through capture of clinical specificity in diagnoses as well as appropriate capture and reporting of healthcare associated conditions and patient safety indicators. The term “proper documentation” can be defined in a myriad of ways ranging from focus upon diagnoses specificity to the preferred more meaningful approach of communication of the entire picture of patient care longitudinally from initial patient presentation to discharge.

Allen Frady in his article published in in the Journal of AHIMA blog March 29, 2018 titled Proper Documentation is Critical to Our Modern Healthcare System (Proper Documentation Critical) makes several notable points related to the concept of proper documentation. All his points are valid and relevant, raising a few key ideas to consider in the context of proper documentation. Appropriate, concise, consistent and contextually correct clinical documentation is essential from a communication of patient care perspective, serving as a cornerstone for all associated healthcare providers in managing and contributing to the patient’s ongoing care. Potentially bad clinical decisions can be made based upon inaccurate incomplete documentation perpetuated by the advent of the electronic health record and the facilitation of improper copy and paste functionality. A reasonable question is what role can CDI fulfill in achieving proper documentation in the record to the extent the record easily tells the patient story in its entirety? Does the unrelenting focus upon diagnoses capture by CDI accomplish a state of proper documentation? Is CDI as a profession contributing to its fullest potential in the healthcare delivery model with an emphasis confined to the narrowest portion of care consisting of charting of diagnoses. While I certainly am not downplaying the importance of diagnoses reporting, what is far more important, germane and fundamental to patient care is the communication of effective and complete patient care where the ultimate standard is another physician can review the original physician’s note and easily assume care where the original physician left off. If I am a patient in a hospital bed being managed by a hospitalist, the expectation is the nocturnist or the next hospitalist coming on his/her tour of duty can safely assume the continued care of myself. Those involved in day-today CDI can undeniably relate to the current challenges of clinical documentation with carry forwards, copy and paste and inclusion of irrelevant or even worse inaccurate clinical documentation in a progress note that perpetuates and permeates itself throughout the record. Undoubtedly, proper documentation has not been achieved yet with current industry efforts at improving clinical documentation.

Where Does CDI Go from Here?

The first step in CDI promoting, advocating and achieving proper documentation is to outline and define what constitutes proper documentation. Proper documentation is definable in many ways depending upon an individual’s point of view; just the same proper documentation can be defined within the following parameters of the record addresses the following establishment and depiction:

• Right care
• Right time
• Right reason
• Right venue
• Right clinical judgment and medical decision making
• Right rationale plan of care
• Right medical necessity
• Right clinical documentation

A record is properly documented if it accurately, succinctly, completely and effectively tells the patient story. An article titled To Be a Great Physician, You Must Understand the Whole Story (Proper Documentation) puts proper documentation in “proper perspective.” Consider the following key points made by Dr. Robert Centor in the article published MedGenMed:

• Great physicians differ from good physicians because they understand the entire story.
• Each patient represents a story. That story includes their disease, their new problems, their social situation, and their beliefs.
• The story includes making the correct diagnosis or diagnoses.
• The story must describe the patient’s context. Who is this patient? What are the patient’s goals?
• The great physician understands the patient and the context of that patient’s illness.
• Only when physicians understand the complete story do they make consistent diagnoses

A great physician understands the patient and the patient store, effectively documenting the patient story in sufficient depth and breadth where the next physician can easily assume care of the patient. It stands to reason as CDI physician advocates and champions that we assume the high road and transform our tune and respect for proper documentation by truly changing current processes of CDI ingrained in our programs. First, we must recognize the inherent limitations of CDI that constrain achievement of optimal program outcomes and initiate steps to address these significant limitations. In my present role as CDI Manager, I am working diligently and tirelessly to address these handicaps through education and sharing of best practices of CDI with hospital administration, highlighting the material benefits and long term sustainable improvement in clinical documentation reached when one focuses upon achieving documentation that accurately reports and reflects the patient story from time of admission to discharge. This level of documentation, not more documentation but more effective documentation, is the standard CDI should be subscribing to, thereby supporting the diagnoses and associated plan of care arrived at and documented by the physician. Unequivocally, our efforts at clarifying and solidifying diagnostic specificity in the record devoid of documentation that adequately and clearly depicts the patient story frequently leads to outside reviewers refuting the diagnoses of record. Recording of the patient story in sufficient detail inclusive of the context of the patient’s illness and recording of all relevant diagnoses with appropriate specificity should be the standard of CDI promoting and attaining “proper” documentation.

Closing Points for CDI to Ponder

I call your attention to Allen Frady’s closing remarks in his article: “There is an important caveat for those looking to build a successful CDI program: strong administrative support is essential. An emphasis on getting documentation right must come from the top-down, from CMS all the way down to the provider, CDI professional, and, finally, to the coding professional. To get documentation right, it is crucial for the physician to have an open mind and be ready to learn.” Strong administrative support for an effective CDI program implies the program is structured and organized to attain and realize meaningful measurable improvement in documentation. I submit to fellow CDI professionals the duty and responsibility to solicit full administrative support of clinical documentation improvement initiatives for all the right reasons in the name of the patient. Let’s begin by transforming current CDI structures and operational processes to one that supports and facilitates appropriate proper documentation in the communication of patient care.