October 23, 2012

How to Score a Touchdown in Clinical Documentation

By Gretchen Dixon

Have you ever pondered why residents and medical students do not understand how to document?

Having been associated with resident physicians and medical students all of my career, I have been baffled trying to comprehend which part of “documentation in a medical record” they do not understand.

Last evening, we had a friend over to watch Sunday Night Football, with the Atlanta Falcons going for a perfect season against the Washington Redskins. Our friend, Peter, who is a first-year surgical resident, was describing how hard it is to meet hospital documentation expectations in a patient’s electronic medical record. As he spoke, it became clear why we as case managers/clinical documentation improvement specialists and coders struggle with physician documentation. As usual, I got on my bandwagon about how doctors just cannot seem to document what we need documented! Then my upstairs light bulb started to become brighter while speaking with Peter.

The deficit is in the education process. DUH! There seems to be a void in Peter’s curriculum regarding documentation, beyond the basics. As we discussed the curriculum and his professors, it appeared there was little interest in teaching anything related to why the details of patient information are necessary. This leaves out documentation specificity, coding, and billing. I inquired if he knew the necessary documentation components to bill out an encounter using evaluation/management levels and he said, “I am going to get another beer!” Whoops—I guess I entered into a realm of knowledge he did not want to go into.

During the commercial break, I attempted a different approach—a different play. I explained to Peter that each tidbit of information documented in a patient’s medical record equates to yards gained down the field toward a touchdown. Reimbursement is the touchdown. The touchdown is comprised of the diagnosis and treatment documented, which translated into codes used for profile data and reimbursement for both the physician and hospital. He got it—another touchdown!

Tidbits of information can be defined as specificity. For example, during the football game, there was a collision between players with a helmet-to-helmet hit and a head bounce off the turf. Ouch. What needs to be documented? How did the patient hurt his head? What are the symptoms? What was done for him on the field? How long did his headache last? The touchdown is in the details.

Healthcare is Changing

The healthcare world as we know it today is changing and we must be willing to invest both effort and time to educate now. How do we start?

On the 50-yard line, we assess where we are, where we are going, and whom we are playing with. Identify all of your physician specialty and subspecialty groups and review the data for each to determine which one has the most queries and/or risks due to vague or incomplete documentation.

Categorize the specialties by highest risk or difficulty and identify the educational opportunities. The action plan should be to provide more clarity, conciseness, and granularity to documentation related to each specialty in a play-by-play method (incrementally). Encourage your quarterbacks (i.e., physician champions), to engage their peers in this documentation improvement process.

During the game, we were able to build a couple of very simple and easy-to-use templates for Peter to use as a stepping stone tool. He downloaded these to his tablet.

How do we educate residents and medical students? Brainstorm to determine the best methods to communicate the higher level of documentation expectations, and include these students in meetings or educational sessions. Only then will they be able to run with the football and score touchdowns. 

About the Author

Gretchen Dixon, MBA, RN, is a consultant at Hayes Management Consulting. She is a Certified Healthcare Compliance Officer, Certified Coding Specialist, and internal auditor with more than 20 years of experience in the healthcare industry, with an emphasis on clinical documentation improvement, compliance, revenue cycle and coding.

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.