importance of clinical documentation in healthcare

Allina Health provided education and support to clinicians, office managers, and office staff, developing widespread understanding of the importance of accurate clinical documentation and the reimbursement impact. The premise of CDI is simple: engage clinicians to improve the clinical documentation in the medical record in "real time" so that it is fit for reporting, analysis and reimbursement. ", Copyright © 2011-2020 BCE Healthcare Advisors. However, documentation of CHF alone in the inpatient setting would not impact the DRG relative weight unless the acuity and type of heart failure is noted in the documentation. Undocumented or poorly documented information relies on memory and is less likely to be communicated and retained. Section 456.057(14), Florida Statutes.”. US Centers for Medicare and Medicaid Services (CMS). Careers   |   Legal Notice   |   Site Map, Reason 3: Hospital/Medical Staff Bylaws and Joint Commission Standards, Reason 5: Public Notice of State Medical Board Disciplinary Actions, Healthcare Compliance Advisors and Featured Staff, The Model Matters: Clinical Documentation Program Comparison, The Top Seven Reasons Clinical Documentation Is More Important Now Than Ever, Double Dipping is Proper Etiquette for Medicare and Medicaid Auditor Contractors", Lost in Translation: Bridging the Language Gap Between ICD-9 and ICD-10,,,,, It is vital for CDI professionals to be aware of the documentation elements that have an impact in the setting in which they work. Documentation is an essential component of effective communication. Dr Samer A Kanaan | Thoracic Surgeon Irvine | Mission Viejo CA [xiv] Target areas for auditors include: DRG assignment, medical necessity, contractor approved issues, and procedures unrelated to the primary diagnosis. … The Importance of High-Quality Clinical Documentation Across the Healthcare Continuum. Tex)) (relying on a survey report from the American College of Obstetrics and Gynecology to not renew physician’s privileges). [iv] Pinellas County Medical Association, available at 3730(4)(A); U.S. Ex. High-quality documentation is also vital to medical decision-making. And the importance of complete, accurate, concise, timed and dated documentation cannot be overstated. Furthermore, a hospital may request a survey that can be used both by a hospital for an internal review and a court.[vi]. Reason 6: Adverse Financial Consequences It’s the job of HIM professionals to find all the pieces and assemble them to illustrate the full picture of a patient’s care. #F0861, Houston, TX – On February 5, 2010, the Board and Dr. Bacon entered into an agreed order requiring Dr. Bacon to pay an administrative penalty…within 90 days. As the delivery of health care and reimbursement methodologies evolve, the importance of a holistic clinical documentation improvement program becomes evident. Association—delivers best practices in All Rights Reserved. Incomplete or missing subjective, objective, assessment, and plan (“SOAP”) notes have the potential to adversely impact the physician and the hospital from legal, financial, and reputational standpoints. Congestive Heart Failure: Prevention, Treatment and Research. [i] “These guidelines can take the form of federal or state statutory or regulatory requirements, professional association and accreditation standards, and health care organization internal policies, protocols and procedures.”[ii] Failure to conform to an established protocol, may, standing alone, constitute enough evidence that the healthcare provider breached the standard of care. Furthermore, if a private citizen brings a claim and the government intervenes, the qui tam plaintiff may collect anywhere from 10-30% of any amount recovered by the government and reasonable attorney fees. While payment may not be the focus when providing healthcare, good documentation remains an arguably strong link to financial performance, which subsequently impacts the ability to continue to provide healthcare services. Clinical Documentation: Why is it so Important? [xi], Reason 5: Public Notice of State Medical Board Disciplinary Actions 1999); U.S. ex rel Hagood v. Sonoma County Water Agency, 929 F.2d 1416, 1419 (9th Cir. health information management and [vii] The financial penalties are significant and enable the government to be awarded treble damages plus civil penalties ($5,000-$11,500 per claim). Even though CMI and the risk adjustment score are two different measurements, they both reflect the patient’s disease burden. [xv] 31 U.S.C. The setting in which a patient receives care is determined by the patient’s physician.1. [vii] Act of March 2, 1863, ch. Action Taken: The physician has entered into an Agreed Order with the board for a period of two years subject to the following terms and conditions: The physician's practice shall be monitored by a board designated physician monitor who shall review selected patient medical and billing records. When patients are discharged or complete a provider visit, they may see another provider in a separate location and setting. The top audit trigger is improper or inaccurate billing. Professional association standards, such as those set forth by the American Academy of Orthopaedic Surgeons (AAOS) are often relied upon and incorporated into the healthcare providers guidelines. There are also a myriad of other reasons that a comprehensive medical record, that includes a detailed history and physical, progress notes, and consults, is vital. Undetected problems in medical records can fester, impacting everything that is … Precise documentation is accurate, exact, and strictly defines the patient’s conditions.3 An example of a diagnosis that should be assessed for precision is the diagnosis of congestive heart failure (CHF). If the outpatient CDI professional focuses on recognizing high-quality documentation and not just elements needed for HCC capture, they can better validate when all documentation meets the characteristic to be of high-quality, which would then accurately represent the disease burden across all settings. Reason 7: RAC and Other Audits Documentation requirements vary by practice setting and by payer. Given the complexity of health care and the fluidity of clinical teams, healthcare records are one of the most important information sources available to clinicians. Principles Of Documentation In Health Care Settings. Medical staff bylaws, hospital bylaws and Joint Commission standards set parameters that promote and ensure quality patient care. §§ 3730(b)(2)-(4) (1986). Medical records are a crucial form of communication. Second, if a condition is not documented as present on the first admission and is included in the Hospital-Acquired Conditions list set forth by CMS, if a patient is readmitted for an item on the list, then the healthcare provider does not get reimbursed.[xiii]. Clinical documentation is also used in the creation of longitudinal patient records (LEPRs), a type of electronic health record (EHR) that includes all healthcare information from all sources for an individual … Sometimes, inadequacy equates to no history and physical or progress notes. Standard of Care. Improved Outcomes. CDI professionals should be aware of the impact of clinical documentation across the continuum of care. patient health information. The anchor on a cruise ship can hold the ship in a certain location or be raised when the ship is sailing. [v] HealthGrades, available at Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. [iii] A physician’s license may be revoked or suspended for failing to keep proper medical records. Investigation of complaints, hearings and disciplinary sanctions are all within the purview of the board. [xiii] Centers for Medicare and Medicaid, Hospital-Acquired Conditions, available at; Deficit Reduction Act of 2005, §5001(c). keeps readers current on emerging [iv] In turn, this negatively impacts a physician’s HealthGrades score. CDI programs that promote high-quality documentation not only support the capture of appropriate reimbursement but also the quality of care provided to the patient by ensuring all the information within the health record is of high quality and supports informed medical decision-making. In order to avoid having to pay back previously reimbursed claims plus interest or going through a lengthy appeals process, better documentation decreases RAC findings. [i][i] James v. Brown, 637 SW2d 914, 918 (Tex. The Board’s action was based on Dr. Bacon’s failure to meet the standard of care and maintain adequate medical records.”. [xiv] CMS, Statement of Work for the Recovery Audit Contractor Program, (last visited Mar. The inpatient setting can be broken into different hospital units based on the patient’s diagnosis or procedure that was performed. The clinical documentation in the health record must support the presence of all patient condition/diagnoses, along with the provider’s assessment and plan for management of each condition, especially chronic conditions. Therefore, the top seven reasons clinical documentation is more important now than ever are: (1) establishes the standard of care; (2) impacts physician state licensing; (3) basis of hospital/medical staff bylaws and Joint Commission accreditation; (4) implicates the False Claims Act for improper billing; (5) public notice of inadequate medical record maintenance by state boards; (6) adverse financial consequences for the physician and hospital; and (7) increased negative outcomes in relation to RAC audits. A characteristic of high-quality clinical documentation is documentation that is precise. However, this should not lead the CDI professional to silo their health record reviews into only clarifying for documentation elements that impact reimbursement, but rather focus on high-quality documentation that accurately tells the patient story. There are seven characteristics that should be seen within clinical documentation for it to be recognized as high quality. 1-866-670-0767 Like the anchor, the documentation supports a comprehensive view of the care provided for any single encounter, it may stop when the patient’s encounter or admission is over but there is a clear record for each encounter. In the outpatient setting the documentation of CHF is enough information for the condition to fall into an HCC. A CDI professional should be aware of all the elements of high-quality clinical documentation so the patient’s disease burden is accurately captured in all healthcare settings. The Golden Thread is the documentation that supports each decision, intervention, or client note that contributes to a complete record of client care that is error free and ready for reimbursement. [v], Reason 3: Hospital/Medical Staff Bylaws and Joint Commission Standards rel Burns v. A.D. Roe Co., 186 F.3d 717, 722 (6th Cir. The advantages of quality clinical data are well known among physicians and the practice of evidence-based medicine, and little doubt exists that CDI can increase hospital revenue.A Black Book Market Research report last year showed almost 90 percent of hospitals with 150 or more beds outsourcing clinical documentation functions made over 1.5 million in healthcare revenue and claims reimbursement after implementing CDI.Bla… rel Holmes v. Consumer Ins. Within each of the areas there are various care-focused groups. Second, because of the revenue a particular physician is generating, his/her disregard for completeness and/or timeliness of clinical documentation is “overlooked.” By not addressing these issues, both the hospitals and physicians are taking significant risks. This is a good example of a time when documentation may impact the patient’s disease burden representation in one setting but not another. Reason 4: The False Claims Act This information is needed to recognize the return on investment when developing and managing a CDI program. The benefits surrounding its success internationally include improved quality and … Clinical documentation must incorporate the concept of the “Golden Thread”. First, the documentation is inadequate and untimely. Initially created in 1863, the False Claims Act (FCA) enables the federal government to combat waste, fraud and abuse against those who are reckless, deliberately ignorant, or knowingly make false representations to the government. A... 3. Four Reasons to Document Properly 1. Johns Hopkins Medicine. issues that affect the accuracy, [x] The caveat is that the information cannot be publically available information. In the outpatient setting some payers will classify diseases into hierarchical condition categories (HCCs); these also have weights associated with them, which can be used to calculate a risk adjustment score. Poor clinical documentation is undermining patient care, hospital sustainability and healthcare data integrity The care of all Australians is significantly impacted by poor clinical documentation. §§1396a(a)(42)(B) and 1395ddd(h). Californian Sentenced to Prison for HIPAA Violation, Information Blocking Implementation Roadmap, HIM’s How to Thrive Guide: COVID-19 Challenges Met, Lessons Learned and Advice to Forge Ahead, Information Blocking and HIPAA: Road to Compliance, Accurate Provider Data Governance Essential for Patient Care, Why Hospitals Need to Rethink Privacy and Information Security Models, Working from Home During COVID-19: Challenges and Solutions, AHIMA Webinar Addresses COVID-19 Medical Record Documentation Challenges. §§ 3729–3733, also called the "Lincoln Law. 1991) (holding that information is not considered publically disclosed if “the communication does not release the information into the public domain such that is accessible to the general population.”). [vi] American Academy of Orthopaedic Surgeons, Code of Ethics and Professionalism for Orthopaedic Surgeons – General Principles of Care, §VII(B)(D) available at; Benson & Benson OB/GYN Center v. St. Josephs Regional Health Center, (2007 WL7120757, 1 (S.D. By not documenting, opportunities to capture CCs and MCCs are lost. 67, 12 Stat. Clinical documentation and coding are similar, as they are also the supportive building blocks in healthcare and can be thought of as foundational as well. Because RAC auditors can also file a qui tam suit, there is an additional incentive. The treatment of CHF is decided based on the type of heart failure and if the patient has any other underlying conditions.4 The documentation of underlying conditions would be considered complete and reliable documentation. DRGs also impact the case mix index (CMI), which is the average of all the DRG relative weights to capture the patient’s disease burden. Medical Boards publically release the findings of disciplinary hearings and can order an administrative penalty for failure to meet the standard of care for not maintaining adequate medical records.[xii]. Healthcare professionals rely on the accuracy of correct... Beware the Snowball Effect. Moreover, Rule 64B8-9.003, Florida Administrative Code, in addition to the above, mandates that the records be legible and contain sufficient information to "identify the patient, support the diagnosis, justify the treatment and document the course and results of treatment accurately..." Finally, the physician should be aware that failure to keep written medical records could subject the physician to penalties ranging from a mere reprimand to a combination of a two-year suspension, followed by probation and a $5,000 fine. Clinical documentation improvement specialists are trained to have a firm grasp the clinical details of high-quality care and to be able to spot gaps in electronic health record charting. Required fields are marked *, © Copyright AHIMA 2020. [xii] Texas Medical Board, (Feb. 17, 2010). Clinical documentation improvement (CDI) is a recent initiative gaining increased momentum in Australia. With FERA amending the FCA, a new basis for liability emerged – knowing retention of an overpayment, regardless of the cause of overpayment. The impact seen throughout the different settings will vary. A good clinical documentation improvement program can not only make life easier for the billing department, but also for the patients themselves. For example, in the inpatient setting some payers will classify diagnoses into diagnosis related groups (DRGs). Keeping proper records improves patients' clinical outcomes once they leave the … [xi] 31 U.S.C. The legal standard of care or the required practice standards in a given situation, form the basis of a legal claim, which is often a state negligence or deceptive trade practice claim, or a component of a federal claim such as the Anti-kickback or False Claims statutes. Just as patients rely on numerous providers and healthcare professionals to maintain a good state of health, passengers on a cruise ship rely on numerous crew members to ensure they have smooth sailing and stay on course. [ii] Ronald W. Scott, Legal Aspects of Documenting Patient Care, p. 163 (2nd ed. These characteristics can be applied across all healthcare settings. publication of the American Health Requirements of clinical documentation and accuracy of data are essential in achieving quality and cost-saving outcomes, regardless of place of service or health care setting. Inpatient care is reserved for a higher intensity of care that is delivered in a hospital setting while outpatient care requires a lower level of intensity and may be delivered either within or outside of a hospital. David Newton, a Clinical Documentation Manager, and Michelle Brooks, a Corporate Director of Case Management in Clinical Documentation Improvement (CDI) at Baptist Health Care, discuss the importance of accurate and timely clinical documentation and how they have seen CDI transform hospital and patient outcomes. Likewise, comprehensive, accurate documentation is important to all stakeholders in health care, from patients to providers, payers to researchers. Reason 1: Standard of Care With this assortment of care settings, it would be detrimental to the patient if a provider only considered the care that was provided in one setting to guide their medical decision-making. [iii] See Delaware Board of Medical Licensure and Discipline (; The Medical Board of California (; Texas Medical Board (; Pennsylvania Department of State, State Health Licensing Boards (; and Florida Board of Medicine ( The quality of medical documentation has several far-reaching impacts, from directly affecting the quality of patient care, to influencing hospital funding. Clinical Documentation Improvement (CDI) is a process to facilitate an accurate representation of healthcare provided through complete and precise reporting of diagnoses, comorbidities, and procedures to ensure the acuity and complexity of the patient is available to be coded. Patients flow through numerous care settings within the vast healthcare matrix, including inpatient and outpatient areas. timeliness, privacy, and security of For patients, documentation ensures the delivery of safe, consistent, quality healthcare. 2003); Ex. The significant role CDI plays in healthcare has become apparent with the transition from the inpatient to the outpatient environment and from a financial to a quality focus. Your email address will not be published. Your email address will not be published. Tammy Combs ( is director, HIM practice excellence, CDI/nurse planner, at AHIMA. Health Information Trends: The Importance of Clinical Documentation Improvement By Megan Ruesink on 11/21/2016 As an aspiring professional in the heath information technology/management (HIT/HIM) field, you know that accuracy and integrity are of the upmost importance in your work. Documentation is often the sole point of communication between nurses of changing shifts. [xv] Therefore, it is imperative that accurate documentation be provided in a timely manner. Up to 70% of nurses surveyed stated they were unable to find an indication in the medical record for a treatment they were administering to the patient. Importance of Medical Documentation Basic Documentation. Medical record documentation is a cornerstone to achieving compliance and optimal patient care. The outpatient setting can be even more diverse, including multiple care locations such as the emergency department (ED), hospital observation care, physician clinics, home health services, and ambulatory surgery. The different healthcare reforms that have been introduced have only served to highlight how critical it is to ensure the maximum accuracy for all documents at all times. In addition to fines and penalties physicians and hospitals may be required to pay if claims were submitted without adequate documentation, medical errors were made, False Claims Act violations, or a licensing board or Joint Commission imposes a fine, there are other areas that are impacted. The physician's three surgeries on a patient contributed to the patient's final condition of disability. The Board’s oversight duties do not end with the initial administration of a license, but rather continues as long as a physician or other health care professional (Physician Assistant or Nurse Practitioner) continue to practice. Sometimes patients will be at one location for their care and the documentation is the anchor that provides the information needed for the healthcare teams to stay on course. 1985). Ensuring an accurate problem list These characteristics include documentation that is:2., Information Management Who Has Rights to a Deceased Patient’s Records? The benefits of clinical documentation improvement. The feedback is designed to fill gaps in documentation such as questions about coding, quality measures and overall care management of a patient. The Importance Of Clinical Documentation Improvement According to The American Health Information Management Association (AHIMA), CDI is so important in the health care world because it has a direct impact on patient care. Communicates with other health care personnel. Aside from an adverse patient outcome, there are numerous ways that healthcare providers are subject to adverse legal, financial, and publicity in relation to clinical documentation. Reason 2: Physician Licensing In healthcare, over the past 25-30 years we’ve seen the use, need, and importance of clinical documentation and coding greatly increase. Documentation communicates the quality of clinical care that providers... 2. This means that if no verbal conversation has taken place, the documented notes must be read by the incoming nurse in order to understand where in the care cycle the patient stands. Complete documentation is that which includes maximum content; reliable documentation is trustworthy and safe.5. In today’s healthcare landscape, clinical documentation is the lifeblood of an organization. Improve Clinical Documentation Quality, Improve Health Care Inpatient hospital care. These DRGs have relative weights that capture the complexity of care and are used for reimbursement purposes. CDI is a process typically used in hospitals that employs specialists who review clinical documents and provide feedback to physicians, says Mark Morsch, vice president of technology at OptumInsight. For a healthcare provider or an RCM stakeholder, the importance of clinical documentation improvement (CDI) cannot be emphasized enough. [viii] 31 U.S.C. Each episode of care should include documentation that clearly supports each episode of care. Accurate and timely clinical documentation by physicians has always been the cornerstone of quality patient care and reimbursement. 20, 2011).

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