Quality Documentation Begins With Acuity, Severity, Specificity and Linkage

Here Are Some Exciting Improvement Efforts Underway:

• Continued partnership with AdventHealth’s Clinical Documentation Integrity (CDI) colleagues to provide focused education based on tracking and trending query type and volume. 
• Dr. Agnes Berlin and Pioneer’s Medical Executive Committee (MEC) are proposing the addition of a ‘Hospital Course’ summarizing major updates on daily progress notes in one line, easing transitions of care between physicians and improving communication with community Primary Care Physicians (PCPs). 
• Chief Quality Officer, Brad Gude, PA-C, is collaborating with a variety of our team members to standardize importable text phrases in CERNER, thereby eliminating unnecessary keystrokes while still capturing accurate and comprehensive clinical diagnoses. 

Key Components of High-Quality Documentation Address Acuity, Severity, Specificity and Linkage. 

1. Tell the story.
   Ask yourself: “What would a fellow clinician need to know about this patient to understand why I drew those conclusions or to pick up where I left off?” 
2. Be thorough.
   If you have a strong suspicion that a condition is present, best practice is to offer an uncertain diagnosis. Associate signs and symptoms with your most likely diagnosis. 
3. Translate findings into diagnoses using your best medical judgement.
   Coders are not permitted to make clinical inferences. Only a clinician may make the determination using their clinical expertise and experience. 
4. Consider doing a documentation time-out.
   Stop and think: “Why is the patient still here? Why are we doing what we are doing?” 
5. Evolve, resolve, and remove.
   If an uncertain diagnosis is ruled in or out, take away the uncertainty. Inpatient hospital billing codes capture uncertain diagnoses as if they were definitively present, while professional fee billing can only code definitive diagnoses. 
6. Recap and Disposition.
   End the note with your plan and a one-line recap of the changes of that day in the hospital course section. Make sure you update the disposition, diet, prophylaxis, fluids etc..