All Entries Tagged With: "communication"
It takes a hospital. . .
A recent hospital audit of 300 medical records turned up some not too surprising facts about physicians. The doctors are still not documenting appropriately, their handwriting is illegible, and the discharge summaries are inadequate.
Recent changes in CMS regulations have made certain wording and diagnosis linking imperative for hospital coding and reimbursement. The new rules are confusing and complicated. Certain words need modifiers, certain diagnosis must be linked to their causative agents, other conditions must be rated as acute, exacerbated, or unstable.
Old dogs need to learn new tricks.
There is an old expression that “You can’t teach an old dog new tricks.” I am starting to wonder if this shouldn’t also include physicians. I work in the Clinical Documentation Improvement office and we strive to educate physicians on the nuances of clinical documentation. This recent audit indicates that we still have a lot of work to do.
I attended parochial school my entire life and I spent most of my formative years having to stay after school for poor penmanship. I still have terrible handwriting and I missed out on a lot of fun. This only goes to explain why I cannot criticize someone for having poor handwriting. The new computer era is upon us and with the advent of electronic medical records it also may be a mute point. I do not give penmanship classes.
However, like that old dog, the problem may be that seasoned physicians are too old to learn new techniques for documenting patient care. Perhaps we need to start educating the physicians sooner, when they are still in medical school.
The problem may be the lack of incentive. Perhaps the physicians need some sort of pay for performance to entice them to change their old habits.
Or the problem may be that hospitals need more upper management support for their CDI departments. Perhaps a series of speeches given by the CEO would get everyone motivated.
The problem may be a lack of educational resources. Perhaps hospitals should invest in teaching tools and educational literature.
The problem may be everything mentioned above and then some.
Clinical documentation teams across the country are working diligently to educate physicians and improve documentation. Blaming the CDI department for the deficiencies of the physicians, will not correct the problem. Secretary of State Hilary Clinton said “it takes a village to raise a child,” cribbing from an old African proverb. Well, maybe it takes a hospital to educate a physician.
CDIs tell the story behind the patient record
I came across this article from HealthLeaders Media the other day. It talks about the importance storytelling in healthcare. I don’t think they were talking about the “once upon a time” kind of storytelling, but more about the kind of storytelling that represents what we writer-types like to call the “narrative arc.” Simply put, everything has a cause and effect whether it’s how some story-book character’s childhood upbringing comes to bear on their philosophical outlook or, in the case of clinical documentation improvement, how a particular patient’s clinical indicators come to bear on his or her inpatient stay.
CDI professionals try to get all the story particulars from all the various characters as they each play their role in the development (and resolution) of a patient’s healthcare plot.
According to the article, facilities in the United States and the United Kingdom are using storytelling to enhance patient history information to get a better sense of how to treat the patient. Storytelling also helps providers develop a relationship with the patient and form a better understanding of an individual case, writes Sarah Kearns.
While I’m not suggesting that we rename clinical documentation improvement specialists “storytellers” I am suggesting CDI professionals take a second to consider the health record as if it represents the “story” of the patient’s life, the story of his or her care. Furthermore, I am suggesting that perhaps expressing your documentation improvement efforts in that way may actually resonate with the physicians and help them understand the important role you also play.
Draft a holistic approach to CDI program development
Clinical documentation improvement (CDI) programs have evolved over the last few years as
Could it really be so simple?
hospital interest in implementing these programs has grown exponentially. Such interest and evolution seems obvious given the healthcare economic climate and Medicare’s decision in the 2010 IPPS proposed rule to factor in a “behavioral adjustment” for supposed increase in hospital’s case mix absent an increase in patient severity and acuity.
Nevertheless, the field of clinical documentation improvement is relatively new and continues to evolve with the growth of CDI programs.
The fundamentals of CDI programs consists of physician education on the merits of complete, accurate, and effective clinical documentation that can be translated into the most clinically appropriate ICD-9 codes in support of patient acuity, patient severity and risk of morbidity, mortality, and readmission. Different approaches to affecting positive change in physician patterns of medical record documentation may be used by CDI specialists. Typically, educational sessions, handouts, documentation tip sheets, written clinical queries, verbal queries, and monthly newsletters are used as part of CDI programs for this purpose.
However, one important item to consider in any program is the definition of “clinical documentation improvement.” To most, the definition consists of ensuring complete and accurate documentation of clinical diagnoses throughout the record in reflection of patient presentation to the hospital, physician treatment and management of the patient, hospital resource consumption and ultimate MS-DRG assignment.
What is missing in CDI programs is a holistic approach. What do I mean by the “holistic approach?” Holistic documentation improvement entails reviewing physician documentation beginning in the emergency room and continuing with the history and physical (H&P), progress notes, consult notes, and discharge summary to ensure complete, accurate, and effective documentation to complement efforts at capturing all reportable diagnoses associated with an inpatient encounter.
CDI at Bat
The outlook wasn’t brilliant for the CDI that day:
The chart stood unattended, with one hour left to stay,
Even the best documentation specialists strike out once in a while.
And then when Dr. Cooney didn’t chart, and Dr. Barrow did no more,
A pall- like silence fell upon the patrons of the floor.
A straggling few got up to go in deep despair. The rest
Clung to the hope which springs eternal in the breast:
They thought, “If only Dr. Casey could get a whack at that,
We’d put up even money now, with Dr. Casey at the bat.”
There was ease in Dr. Casey’s manner as he stepped into his place:
There was pride in Dr. Casey’s bearing and a smile lit Dr. Casey’s face.
And when, responding to the query, he lightly doffed his hat,
No stranger on the ward could doubt ‘twas Dr. Casey at the bat.
The usual sneer had fled from Dr. Casey’s lips; his teeth clenched in rage:
He pounded with cruel violence his pen upon the page.
And now the nurse she holds the query, and now she lets it go,
And now the air is shattered by the force of Dr. Casey’s NO!
Oh, somewhere in this favored land the sun is shining bright,
The band is playing somewhere, and hearts are light,
And somewhere men are laughing and little children shout;
But there is no joy at the hospital – mighty Dr. Casey had struck out.
Happy Mother’s Day the CDI way
My wonderful sister, an emergency room nurse for more than 20 years now and mother of five, couldn’t stop laughing at this YouTube video dubbed “The Mom Song,” by Anita Renfroe off her album Total Momsense. The song uses the William Tell Overture to frantically rush through all the outrageous things a mom might say during the course of the day.
I’m wondering how many of you CDI specialists feel more like documentation “moms” to the errant physicians who submit lackluster documentation. I can hear how the song would go. . .
“Write it down. Write it down. Write it down right now! If you don’t write it, we can’t code it, don’t you know that by now? Is that your signature! Where did you learn penmanship?!? Was this acute or dystolic? Did you mean renal failure or kidney disease? Please don’t text while I’m lecturing. . . Please refain from chuckling . . .”
Okay, that’s enough from me. Let me know if you come up with better lyrics. But here’s a clip of the video from YouTube. Happy Mother’s Day!
Coders deserve ’superhero’ kudos
Hidden deep within the HIM office hides the coders’ universe. These hard working individuals put in long hours at small cubicles, staring at multiple computer screens. They are the unsung heroes of the hospital. This group of individuals would probably shun any fancy accolades, tell you they are simply doing their job, but this is an understatement.
Coders deserve a hero's recognition.
The coder is a type of superhero, bestowed with powers beyond that of a mere mortal. Physicians frequently use abbreviations that boggle the mind. Web sites abound with dictionaries for approved abbreviations, but low and behold the physician will always come up with something new. GLM, for example, sometimes refers to a patients’ good looking mother. ARBF means awaiting return of bowel function. The list goes on and on, but curiously the coders know what the collection of symbols stand for.
Coders also decipher the worst handwriting in the universe and make sense out of the senseless. They memorize physician signatures and read words where others only see squiggles. Coders know the DRG number of most illnesses.
Hospital reimbursement would come to a standstill were it not for the coders, making them more powerful than a locomotive. The “super coder” can read through a chart faster than a speeding bullet. They may not be able to leap tall buildings, but they sure can find the principle diagnoses in a single bound.
The Clinical Documentation Improvement department is still fairly new to the hospital scene and the profession has gone through many changes even within that period of time. Coders have been an integral component throughout this transition and it is clear that these modest groups of individuals are SUPER!
Chemotherapy documentation challenges warrant CDI attention
Given the extremely high cost of chemotherapy services, it is likely that third-party payers, including Medicare, will scrutinize these services, says Glenn Krauss RHIA, CCS, CCS-P, C-CDIS, in an article for JustCoding.com.
Here is a breakdown of areas generally targeted by payers including Medicare and their related documentation difficulty:
- Medical necessity for the supplied diagnosis: Often the clinician fails to provide the specific location of the cancer. A clinical documentation specialist can query the physician to ensure appropriate documentation.
- Coverage exclusion for specific drugs based on clinical trial effectiveness: Coders should reference local coverage determinations that generally spell out which diagnoses are considered covered benefits for common chemotherapeutic agents.
- Proper charging and billing of drug units: Just documenting patients’ nausea and vomiting is not always sufficient to support payment of anti-emetic medicines.
- Documentation to support IV administration units of service: Accurate coding for this requires clear start and stop times for IV chemotherapy administration. It is particularly problematic because clinicians do not always document the order of sequential therapy.
CDI programs might consider designating a team member specifically for the chemotherapy service line, Krauss says. A part-time specialist or member of the existing team may be enough depending on the monthly volume of patients in the chemotherapy department and the number of new patients who begin chemotherapy each month.
Focus initially on validating documentation and providing feedback to clinicians regarding documentation of IV therapy administration. The CDI specialist can help bridge the gap between customary medical record documentation and the level and detail of documentation necessary to properly and accurately capture all IV administration charges.
JustCoding.com subscribers can read the complete article online.
Three tips to maximize the role of physician advisor
It’s been a year or so since you’ve started your CDI program. So far, so good. The administration thinks your team took miracle-worker training. So much so, they’ve agreed to let you add a physician advisor (PA) to the staff. And you’re all for it. You know a PA will add credibility to your documentation improvement efforts, act as a liason with difficult physicians, and help your staff memebers investigate documentation deterrents. Here’s how:
- Disseminate CDI program goals: CDI specialist’s struggle to strike just the right documentation chord to win physician support. Improved documentation equals better patient care, improved scores on the physician’s scorecard, improved hospital care, and of course the elephant in the room no one’s supposed to mention—better reimburment. While the primary goals of CDI programs are indeed the improved care of the patient, physicians sometime think the facility cares only about the bottom line. A PA who puts his support behind the CDI program explore the benefits in a concrete way that a CDI specialist with coding or nursing background cannot.
- Define communication issues and barriers: Maintain a consistent dialogue with your PA. Allow him or her to bring you constructive criticism from fellow physicians. Maybe cardiologists hate it when CDI specialists bug them at lunch time. Maybe the internists, however, think lunch time is the best time for documentation education. In this way the PA can provide invaluable tips for how to perform better.
- Update CDI team on relevant clinical issues: Ask your PA to review existing physician query forms and offer suggestions for how to improve them. Inaccurate, or clinically vague query forms cause physicians confusion. A PA who can head off these potential disputes can help put your CDI program ahead of the game. It’s a physician’s role to understand the latest clinical research. They can help your team understand it too.
Join Mark S. Michelman, MD, MBA, (Morton Plant Mease Health Care System) and Trey La Charité, MD (University of Tennessee Clinical Documentation Integrity Project) for the ACDIS audio conference “Physician Advisors in CDI: Take a Team Approach to Achieve Success and Credibility” on Tuesday, April 14, at 1 p.m. (Eastern).
On the program, the duo will discuss strategies to establish a successful CDI team structure, types of expectations and limitations you should place on your PA, as well as methods to quantitatively measure the progress of your PA and CDI team.
Spring ideas to woo physician support
Chocolate bunnies, marshmallow chicks, and jelly beans all bring to mind the magic of springtime. Fill a clear bag with fake grass and a few candies, tie it with a ribbon and attach your business card.
A little sweetness goes a long way.
You now have a great little thank you gift for your physicians and allied health professionals. We are all just children at heart and even the most serious surgeon will crack a smile when he sees the festive little treats. It doesn’t take a big budget to let someone know they are appreciated. Include a few documentation items, such as pocket cards, and hospital pens and now you are getting two for one—appreciation and education. This practice of passing out goodies can also be repeated for fall and winter holidays, keeping documentation fresh on the minds of your medical staff.
Keep your creative side open to suggestions when dealing with difficult doctors. Share your ideas with others and together, everyone can reap the rewards.
Effective communication equals a CDI nurses’ strength
Good communication is a key attribute of a successful clinical documentation improvement
specialist (CDIS). The CDIS must be able to function in a variety of different settings. These include the CDIS office, the patient care unit, and presenting at rounds. All require flexibility, quick thinking, and a sound knowledge of clinical documentation policies.
Many hospitals have been reluctant to use nurses in the role of CDIS, adhering to the belief that nurses cannot be retrained to think like coders. Why would anyone want them to? Nurses bring their own qualities and strengths to the job.