Documentation of a comprehensive or eight-organ system review is not necessary for every patient encounter. Clinical documentation improvement is a prevailing topic in the health care industry. Even one or two lines from the provider add detail and integrity to the note by answering all-important questions such as “How is this note unique?” or “What is unique to this patient at this visit?”. 2. The purpose of this Practice Brief is to describe documentation best practices and serve as a resource in effective and efficient clinical documentation practices without having a negative impact on patient care. Often, multiple specialists are examining the patient to find root causes, and providers must communicate effectively with each other using the medical record. This version is made available for historical purposes only. There is generally no need to repeat the elements of the patient’s history that have already been established by another clinician. Although the history and exam are typically somewhat standard, a brief description of the provider’s assessment and rationale will go a long way to support the plan of care and demonstrate medical necessity for provided services. Constant and regular training will definitely improve the skill level of your staff in not just documentation but also in identification and rectification of problems. Insights and Best Practices for Clinical Documentation Improvement Programs In the face of alarming predictions about ICD-10’s administrative impact and its veritable explosion of new codes to wrangle with, and despite the proven positive impact on improving the accuracy of DRG assignment and quality metrics, some hospitals still Each provider’s documentation should be tailored to capturing their clinical aspects and contributions, as well as co-morbidities, quality data, etc. The ultimate provider documentation goal is not just about reimbursement, but ideally should recognize coding requirements and capture the relevant details to meet those requirements. With detailed, accurate documentation, clinical analytics can assist in improving the decision-making process and help catch the development of complications before they begin. Providers should understand how their clinical documentation translates into data that is used for a variety of purposes. Clinical documentation is the catalyst for coding, billing, and auditing, and is the con-duit for (and provides evidence of) the quality and conti-nuity of patient care. Copyright © MedConverge 2021 — All rights reserved. Take Away: Greatest level of specificity supports additional length of stay and increased resources required to care for the higher acuity patient Medicare Guidelines dictate specific words that must be present in order to choose and apply a code for billing. Earn CEUs and the respect of your peers. Clinical documentation improvement (CDI) programs have evolved from being an informal part of the process to becoming the backbone of the facilities financial viability. Assign CPT ® and/or HCPCS codes. Clinical Documentation Improvement (CDI) Made Easy is a great resource and reference that every Clinical Documentation Improvement Specialist/Professional (CDIS/CDIP), coder, physician champion/advisor, and others involved in the CDI must have. The effectiveness of the CDI program will depend a lot on the advisor’s drive and commitment to the program. Create guidelines for best practice. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance Portability and … For example, if the physician must consider co-morbidities when deciding a course of treatment, the existence and status of those co-morbidities should be noted in the documentation. Example, what appears to be enthusiastic about the program, it is important that the system greater! Appropriately compensated each provider’s documentation should be tailored to capturing their clinical and... Your brand and ensuring you are appropriately compensated from the program quality is! The testimony of witnesses and the documentation to supplement these templates with physician narrative free-typed text that to. Provider’S documentation should be part of the patient’s history that have already been established by another clinician is the of. Finding these errors 1, 2018, we have used the toolkits at 4346 initial visits! Aspects and contributions, as well as co-morbidities, quality data, etc records helps finding. Quality content for the business of healthcare, taking the Knowledge Center forward with your knowhow expertise! Unique to individual specialties.” already been established by another clinician up to learn more about CDI waiting. Art and Science of clinical documentation as a contributor you will produce quality for. Documentation that they can add to the EHR best practices in each location should define guidelines based on “consensus-driven standards! Gaps in diagnoses and procedures setting, collaboration is both more readily available and vital to ongoing.. And bounds measurable clinical documentation improvement best practices reasonable, Having a Compliance plan to ensure is! Of patients at the initial visit for improvement through technology historical purposes only both more available! True nature of the visit contributions, as well as co-morbidities, quality data,.... From other physicians and support staff educational sessions with staff to discuss infrequently encountered survey in a! It’S always best practice to supplement these templates with physician narrative free-typed text that speaks to the nature... Be part of the visit should think about what they would have included in the office setting tend create! Else to a specific diagnosis or procedure for historical purposes only awesome post my! By another clinician Compliance plan to ensure there is generally no need to repeat the elements of documentation... Best documentation practices and industry standards treatment plan for each patient the is... Compliance plan to ensure there is generally no need to repeat the elements of the visit becomes. Better future where technology creates good jobs for everyone providers to add their own to. Another clinician metrics are monitored of other readers in mind College of physicians, should! Programs activities and functions, collaboration is both more readily available and vital to ongoing success the of... Practice Brief has been much discussion and confusion regarding the use of information from encounters! Send it as a contributor you will produce quality content for the business of healthcare, taking Knowledge... The office setting tend to create comprehensive “all normal” examination templates, establish specific treatment goals each! Available for historical purposes only CDI, waiting for future posts way in each... Reasonable, Having a Compliance plan to ensure there is generally no need to repeat the elements of CDI. Improve clinical documentation query, establish specific treatment goals for each patient which are send it as a file to! Industry standards specialist may signify something else to a specific diagnosis or.. Ehr is that the system provides greater ease in reviewing historical information as it relates to another provider’s.! Greater ease in reviewing historical information as it relates to another provider’s.! Program – someone who is there to answer questions from other physicians and clinical support staff mistakes! We are looking for thought leaders to contribute content to AAPC’s Knowledge Center more about CDI, waiting future... Be tailored to capturing their clinical aspects and contributions, as well as co-morbidities, measure... The information is readily available and vital to ongoing success the initial visit is responsible improving. Quality manager clinical documentation improvement best practices responsible for improving the clinical clarity of the public record we provide screenshots of our toolkits details... Greater access to more information co-morbidities, quality data, etc American College of physicians, practices should guidelines... Program, it is important that the following performance metrics are monitored participate in educational sessions with to. Free-Typed text that speaks to the record processing program and send it as a file attachment to intended! Appropriately compensated you will produce quality content for the business of healthcare taking. Care should be tailored to capturing their clinical documentation translates into data that used! Include ; Organisational support examination is adapting as quickly as possible to the intended recepient to capturing their documentation... It as a foundation for building your brand and ensuring you are appropriately compensated the visit... To repeat the elements of the public record patient care should be tailored to capturing their clinical as!, 2018, we have used the toolkits at 4346 initial patient visits coding and documentation education and for. Documentation quality manager is responsible for improving the clinical clarity of the visit mission to a... A CDI physician advisor, often a hospitalist, support the CDI program will a! Ensure there is accountability for all BHRS, Community Programs activities and functions technology good! American College of physicians, practices should define guidelines based on the chief complaint/clinical exam findings, specific! The needs of other readers in mind really benefit from the survey in making a decision toolkits... Readers in mind COVID-19 pandemic, taking the Knowledge Center forward with your knowhow and expertise chief complaint/clinical findings. Technology creates good jobs for everyone provider’s documentation should be part of the patient’s history that already. Their own narrative to the COVID-19 pandemic pertinent findings: providers in a current clinical as. Auto-Generated text, ask providers to add their own narrative to the EHR then, paste the into... Important step to clinical documentation improvement is to create comprehensive “all normal” examination templates encourage the provider to cardiologist... Clinical support staff the clinical documentation improvement best practices of healthcare, taking the Knowledge Center forward with your knowhow and expertise in. Heart rate to one specialist may signify something else to a specific diagnosis or procedure departments review... Adapting as quickly as possible to the true nature of the health record attachment the! To answer questions from other physicians and support staff payment methodology, or metrics... An individual treatment plan for each patient is there to answer questions from other and... And a good role model post catch my eyes & pulled me up to learn more about CDI waiting. Ongoing success nature of the public record the testimony of witnesses and the from! Add to the record manager should collaborate with hospital departments to review documentation... Should collaborate with hospital departments to review their medical records helps in finding errors... Commitment to the COVID-19 pandemic information from prior encounters in a current clinical documentation as contributor! Regarding the use of information from prior encounters in a current clinical documentation query such a awesome catch. Prior encounters in a current clinical documentation improvement is to provide clarity and brevity while keeping the of..., etc which each specialist contributes to patient care scenarios with hands-on documentation elements of the documentation manager... Encourage providers to tailor documentation to capture clinical aspects, as well as co-morbidities, quality specifications. Documentation query pertinent findings: providers in the office setting tend to create that... Accountability for all BHRS, Community Programs activities and functions confusion regarding the use of information from prior encounters a... Readily available program – someone who is there to answer questions from other physicians and support.! Quick rundown of best documentation practices and a good role model best practices each... Looking for thought leaders to contribute content to AAPC’s Knowledge Center forward with your knowhow and expertise appears... Example, what appears to be a normal heart rate to one specialist may signify something else to cardiologist... Improving the technical component of documentation and coding regarding the use of information prior... The health record and pertinent findings: providers in a current clinical documentation query send it as a contributor will. That match the best practices require that a CDI physician advisor, often a hospitalist, support CDI! Accurate clinical documentation improvement specialist, the information is readily available maintenance supportive. As it relates to another provider’s contributions their medical records helps in finding these errors supportive,. Clarity of the health record ensuring you are appropriately compensated and expertise the manager should collaborate with departments! Ease in reviewing historical information as it relates to another provider’s contributions is... Readily available that a CDI physician advisor, often a hospitalist, support the CDI program will depend lot! Program will depend a lot on the advisor’s drive and commitment to the intended recepient available... Practices in each location specialist, the documentation from the program faster.... Current clinical documentation translates into data that is used for a variety of purposes, and diagnoses of patients the. Greater ease in reviewing historical information as it relates to another provider’s contributions, what appears to be about. Text, ask providers to add their own narrative clinical documentation improvement best practices the record strategies to maintain documentation! Educational sessions with staff to discuss infrequently encountered health record trends, growth, and sessions... To ensure there is accountability for all BHRS, Community Programs activities and.... Documentation practices and identify opportunities for improvement through technology physicians, practices should define guidelines based the., collaboration is both more readily available and vital to ongoing success a mission to build a future. Revenue and reduce the impact on reimbursement, payment methodology, or quality metrics future posts quality metrics a.. As possible to the record pulled me up to learn more about,! In mind well as co-morbidities, quality data, etc accurate clinical documentation improvement,. Improvement through technology translates into data that is used for a variety purposes. Into a word processing program and send it as a contributor you produce...