Talk about documentation catches, simple mistakes cause profound costs
Sometimes documentation mistakes caught by CDI professionals are the simple ones. Like an incorrect date. I recently came upon this news brief from New York Injury News which outlined the trials of HIV patient who lost his coverage due to inaccurate documentation of a blood-test date.
You find vital information in the medical record everyday. Tell us about some of your 'best find' stories.
As compassionate people living day-to-day it’s easy to vilify the insurance company for dropping a sick person from its coverage rosters, or point the finger at the patient for not keeping better tabs on his or her clinical and coverage information. Yet CDI professionals well know the costs of seemingly simple mistakes. This particular case ended up costing the insurance company, Fortis, $10 million for inappropriate denial of healthcare coverage and added untold difficulties to a young man’s life.
Well, I know that CDI specialists catch these seemingly simple mistakes all the time. So here’s a special request to ACDIS Blog readers—wouldn’t it be nice to receive recognition for those otherwise unseen documentation catches you make everyday? Send me your funniest, most heart wrenching, or simply ‘best catch’ documentation stories by the end of October. We’ll run them by our editorial panel and pick the best to publish. E-mail me at mvarnavas@cdiassociation.com.
About the Author: Melissa Varnavas, CPC, ACDIS associate director, editor for CDI Strategies, CDI Journal. She has several writing awards from various newsletter and newspaper organizations.
Melissa Varnavas | Nov 16, 2009 | Reply
I received this from Kathy Shumpert, RN, Clinical Documentation Improvement Specialist at Howard Regional Health System:
The best catch I can recall involved a dictated H&P. Buried within the past medical history, I was stunned to find the patient had an intra-ocular breast implant.
I frequently use this as a teaching example with physicians and end our conversation with, “it gives a whole new meaning to my, what big eyes you have.”
I get lots of laughs over a poignant moment in transcription. Lesson learned: read, read, and reread
Melissa Varnavas | Nov 16, 2009 | Reply
Lori Schmitz, RHIA, documentation specialist team leader for Mississippi Baptist Health Systems, in Jackson, recounted how a documentation explained that a patient presented to the hospital post a laparosopic nephrectomy due to a piece of chicken pot pie getting lodged in his throat, which resulted in some hypoxia that could not be treated conservatively. Initially, says Schmitz, the report said “chicken potassium pie”.
Send us your ‘catches’ and we will run them by our editorial staff and pick the best to publish. E-mail Associate Director Melissa Varnavas at mvarnavas@cdiassociation.com.