Clinical Documentation in the Inpatient
Setting
Outline
• Documentation For Compliance
• Rules of the Road
• Clinical Documentation Improvement
Program (CDIP)
• Documentation Examples
Documentation For Compliance
H&P Required Elements
Must be completed within 24 hours of admission or 30 days prior
to with update day of admission
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Chief Complaint
History of Present Illness
Past Medical History
Medications
Allergies
Immunizations
Family Medical History
Social History
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Substance Use
Review of Systems
Physical Examination
Labs & X-ray Findings
Analysis of Admitting Problems
Problem List
Plan
Consultations
Common Issues with H&P
• Handwritten H&Ps:
 Document not dated/signed
• Incomplete Reports:
 Missing physical evaluation, past medical history, and plan
• Forget to update the H&P at the time of admission if
documented within past 30 days
Discharge Summary Elements
Due the Day of Discharge
• Name of attending
physician
• Patient Name
• Admit Date
• Discharge Date
• Principal Diagnosis
• Principal Procedure
• Hospital Course
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Condition on Discharge
Activities
Diet
Follow-up Appointments
Medications
Copies of Summary sent to
(PCP, Referring Physician,
Consultants)
Common Issues with Discharge
Summary
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Common Missed Elements
Admit Date
Condition on Discharge
Activities
Diet
Brief Post Op Note Elements
• Name of surgeon, proceduralist, and assistants
• Procedure performed and a description of the
procedure
• Findings
• Estimated blood loss
• Specimen(s) removed
• Postoperative diagnosis
RC.02.01.03
Common Issues with Brief Post Op
Note
• “Findings” left blank
• Doctors must amend or attest for anything done by
medical student
• All paper brief post op notes must be signed, dated,
and timed by doctor
Contact Information
Linda McNeil, Assistant Director of
MIS
322-3857
Linda McNeil, Assistant Director of
MIS
322-3857
Adult Medical Records Hub
322-2205 and 343-3060
History & Physical contact information
Ben Giles 343-1659
Discharge Summary contact information
Alisa Maloney 343-4449
Brief Post Op Note contact information
Adult Medical Records Hub
322-2205 and 343-3060
VCH Medical Records Hub
936-5278
VCH History & Physical contact
information
Amaris Scott 343-8510
VCH Discharge Summary contact
information
Amaris Scott 343-8510
VCH Brief Post Op Note contact
information
VCH Medical Records Hub
936-5278
Rules of the Road
The Purpose of the Medical Record is:
• to serve as a basis for planning patient care and for continuity in
the evaluation of the patient's condition and treatment;
• to furnish documentary evidence of the patient's medical
evaluation, treatment, and change in condition during the
hospital stay, during an ambulatory care or emergency visit to
the hospital;
• to document communication between the responsible
practitioner and other health professionals who contribute to the
patient's care;
• to assist in protecting the legal interest of the patient, the
hospital and the responsible practitioner;
• to document for the purposes of third party payment that a test
or procedure is medically necessary, has been ordered, has
been done, and a result (in the case of tests) is in the chart.
TDKD
• The history, examination and decision making process
for diagnosis and treatment are the key elements of a
provider’s note for each patient encounter. Those key
elements should be concisely described in the note
using the following points (referred to as TDKD)
concisely:
• What the author Thought about each issue
• What the author Did about each issue
• What others need to Know about each issue
• What others need to Do about each issue
Clinical Documentation Improvement
Program (CDIP)
What Is A Clinical Documentation
Improvement (CDI) Program ?
• A CDI program is designed to improve inpatient record
documentation by establishing a coordinated, systemic process
utilizing a concurrent review team to strengthen communication
between caregivers, physicians and the coding professionals
• Ensure that the clinical documentation in the patient record
accurately reflects the patient’s principal diagnosis (reason for
admission)
• Secondary diagnoses (co morbid conditions) are documented
• Capture procedures performed
Provide an accurate picture of the patient’s acuity, severity of
illness, and expected chance of mortality for this particular
hospitalization
Why Implement A Clinical
Documentation Improvement Program?
• New laws and regulations, ongoing federal reforms,
and payer initiatives are increasingly aligning quality
outcomes with financial incentives and
reimbursement
• Medicare and many third-party insurers now
consider patient severity of illness and postadmission complications when calculating payment
• At the same time, accurate capture of patient acuity
and risk of mortality impacts your hospital’s case
mix index (CMI), which influences quality outcomes
and hospital performance reports made available to
consumers
Secondary Conditions Are:
- additional conditions that affect patient care in terms of
requiring clinical evaluation, therapeutic treatment,
diagnostic procedures, extend the length of stay, or
increase nursing care and/or monitoring – “ resource
utilization”
• In addition these conditions also affect the expected
mortality % assigned to each discharge
- These conditions are referred to as “major co morbid
conditions”(MCC) or “co morbid conditions” (CC)
Do Severity and Risk Adjustment Really Make
PRINCIPAL DIAGNOSIS & Procedure: Subarachnoid Hemorrhage with
a Difference?
Repair of Aneurysm
Original Documentation
Additional Documentation
Secondary Diagnosis
Occlusion Specf Artery W Infarction
Aphasia
COPD
ABLA
Repair of Aneurysm
Vent > 96 hours
Occlusion Specf Artery W Infarction
Aphasia
COPD
ABLA
Coma
Acute Respiratory Failure
Repair of Aneurysm
Vent > 96 hours
APR DRG
21 Craniotomy Except for Trauma
APR DRG Severity of Illness
3 Major (Weight 4.7570)
4 Extreme (Weight 8.6888)
APR DRG Risk of Mortality
1 Minor
4 Extreme
APR DRG Risk of Mortality %
0.0064%.
0.4438%
21 Craniotomy Except for Trauma
Impact of MCCs and CCs on a
Neurosurgery DRG
V24 DRG
Intracranial Vascular
Procedures
DRG 528
Weight 7.0543
MS-DRG 20 Intracranial
Vascular Procedures With A
PDX of Hemorrhagic
(with a major co morbid
condition)
Coma
-Weight
7.7073
MS-DRG 21 Intracranial
Vascular Procedures With A
PDX of Hemorrhagic
(with a co morbid condition)
Cachexia
-Weight
6.7021
MS-DRG 22 Intracranial
Vascular Procedures With A
PDX of Hemorrhagic
(without a major co morbid
condition or co morbid
condition)
-Weight
5.6085
Do Document
* Significant acute diseases
*Acute exacerbation of significant chronic
diseases
* Advanced or end stage chronic diseases
* Chronic diseases associated with a systemic
physiologic decompensation and extensive
debility
Definitions Mortality O/E
 Observed mortality – actual inpatient deaths
 Expected mortality – those inpatients who are
expected to die during the hospitalization based
on the clinical documentation in the medical
record
 OE Ratio – The number of observed deaths
divided by expected mortalities
2009-05
2009-04
2009-03
2009-02
2009-01
2008-12
2008-11
2008-10
2008-09
2008-08
2008-07
2008-06
2008-05
2008-04
2008-03
2008-02
2008-01
% Deaths (Exp)
2007-12
2007-11
2007-10
2007-09
2007-08
2007-07
% Deaths (Obs)
2007-06
2007-05
2007-04
2007-03
2007-02
2007-01
2006-12
2006-11
2006-10
2006-09
2006-08
2006-07
2006-06
2006-05
2006-04
2006-03
2006-02
2006-01
2005-12
2005-11
2005-10
VUMC UHC O/E Mortality by month (Oct 2005-May 2009)
Mortality Index
4.00
3.50
3.00
2.50
2.00
1.50
1.00
0.50
0.00
Concurrent Review Process
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The CDC staff will query when they suspect a complication or co morbidity
exists but has not been documented or specificity is required. The primary
mode of contact is in email form. Occasionally the queries may be verbal.
The CDC staff enters the data into our tracking software. A report is then
generated monthly that gives the percent of the time that a particular service
and/or clinician responded to the query and what particular diagnosis the
CDC was looking for.
This report is sent to the Chief, Chair, department head or designee to review
and report out to the faculty. The queries are tracked as being “Agree” (with
subsequent documentation of the diagnosis in the medical record),
“Disagree” meaning that the clinician didn’t agree with the query, “unknown”
meaning the clinician was asked but doesn’t know, and “No response”.
We ask that if the provider disagrees with the query or believes that the
query needs to go to another provider that they let us know immediately so
that we can contact the appropriate physician with our query. Please do not
ignore the query
Documentation Examples
Documentation of Heart Failure requires acuity, side,
systolic/diastolic and etiology when known.
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Acute systolic heart failure
Acute on chronic systolic heart failure
Acute diastolic heart failure
Acute on chronic diastolic heart failure
Acute combined systolic and diastolic heart failure
Acute on chronic combined systolic and diastolic heart failure
Left heart failure
Unspecified systolic heart failure
Chronic systolic heart failure
Unspecified diastolic heart failure
Chronic diastolic heart failure
Unspecified combined systolic and diastolic heart failure
Chronic combined systolic and diastolic heart failure
Acuity =A“acute”, “chronic”, or “combined”
Side = “right”, “left”, or “combined”
History & Physical
• Assessment and Plan:
• Ms. X is a 73 year old female with h/o HTN, COPD, Dementia and
brain and lung cancer presenting w/ 2 days of dyspnea and
wheezing. No signs or symptoms suggestive of pneumonia. Suspect
COPD/emphysema exacerbation.
FINAL NOTE AND DISCHARGE
SUMMARY
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Synopsis/Reason for Hospitalization/Principle Diagnosis:
Synopsis:: Ms. X is a 73 year old female with h/o HTN, COPD, Dementia and brain and
lung cancer presenting w/ 2 days of dyspnea and wheezing. No signs or symptoms
suggestive of pneumonia. Suspect COPD/emphysema exacerbation. CXR showed
bibasilar opacities. Ready for discharge home with family today.
Diagnosis/Hospital Course/Treatment:
COPD exacerbation [resolved]: - continue supplemental oxygen
- continue nebulizers
- prednisone 40mg daily, tapering
- Resolved with treatment
Community-acquired pneumonia: - CXR showed increased bibasilar opacities
- started on oral Levaquin, will finish course at home
Disposition: - resides at home with family
- SW aware
- ready for discharge home with family today
- spoke with family in room before discharge and updated on medication changes and
new abx, very agreeable and will have patient follow-up with PCP
Example
• PHYSICAL EXAMINATION: GENERAL: Welldeveloped, well-nourished man who appears
comfortable, and in no apparent distress.
• VITALS: Temp: 96.0 deg FP: 94 RR: 18 BP:
128/93 Height: 72.1 in (10/22/09) Weight:
108.91 lb (11/17/09) O2 sat: 100 % on room air
• Cachetic man lying in bed in NAD, has just
vomitted small amount of non-bloody, nonbilious emesis course
• BS bilaterally rrr, 0 m/r/g
• abdomen soft, mildly distended. no peritonitis
Pt. weight 108#, height 6’1”- has esophageal cancer
The conflicting documentation was in the same
progress note
Questions?
• Stephanie.A.Hays@Vanderbilt.edu
• 322-0663