Clinical Documentation Improvement and Integrity Neurology Service Line Resident Presentation May 18, 2015

2 Lynne Gregson, RN, BSN,CCDS ICU

3 Katherine Grant, RN,BSN, CCDS 11400/

4 Patty Girard, RN

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Administrative Data Age Race Principal Diagnosis Secondary Diagnoses w POA Gender Payor Procedures Co-morbid conditions Risk-Adjusted Statistical Models Expected Mortality Expected Length of Stay Expected Readmissions Expected Complications Expected Cost Risk- Adjustment 7

Who Risk-Adjusts Our Administrative Data? 7

How does what you write affect administrative data? Traditional physician language does not always translate into coding language Often a plan is written with no diagnosis spelling out what is being treated Coders cannot translate Coders have to code from physician notes; not from nursing notes or from diagnostic test reports 8

Dashboard 9

Why should physicians care? Business of Medicine –Profiling websites publish data on the internet –Profiles are used for both commercial and public use –Patients are savvy consumers, they utilize profiles to select provider Future reimbursement methods will likely incorporate profiles in the formula Your attendings are fixing these notes!!!! 10

Why learn it now? Documentation becomes a habit!! This skill will make you more desirable to facilities and/or practices in your future 11

What can you do to help and develop your documentation? Overall goal is to accurately reflect the patient’s true severity of illness Continue to focus on clinical care Utilize tip cards Think in Ink!! Respond to queries from your clinical documentation consultant Ask questions if you need clarification

Basic Documentation Document reason for inpatient admission Document possible, suspected or probable conditions at time of discharge based on signs, symptoms and treatment provided Clarify, after testing, all conditions have been ruled in/ruled out Document in progress notes any significant finds in labs, radiology, path etc Every medication ordered should have corresponding illness Document all conditions being treated, evaluated or monitored to highest degree of specificity

MLS/Mass Effect If midline shift or mass effect are noted on imaging the appropriate documentation should include: Brain Compression Herniation (if appropriate) Cerebral Edema (if appropriate)

Common Queries Coma Encephalopathy (what kind?) Cerebral Edema Brain Compression Hemiparesis/hemiplegia r/t old CVA 23

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End of Life/Palliative Care DNR/DNI = palliative care Important to accurately document patient’s extreme severity of illness and risk of mortality Patients need resources and are still monitored, so need to document the dying process Coma Agonal respirations Respiratory failure Renal failure

Case Study #1-H&P 28

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Case Study #1 Before Query 30

Case Study #1-Query 31

Case Study #1-Query 32

Case Study #1-Query 33

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After Query 35

Case Study #2 Patient p/w: –BP 220/130 –HA, blurred vision, n/v, confusion –Abatement of s/s after treatment of blood pressure Documentation included “hypertensive emergency, possible TIA” 37

Queried for Hypertensive Encephalopathy 38

Secondary Conditions 39

Without CHF Acuity/Type 40

After Specifying Acuity of CHF 41

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Wrap-up The story of how we cared for the patient is clear, concise and easily translated by coding Every treatment needs a diagnosis!!! Continue to document conditions as they resolve (i.e., sepsis resolved) Documentation Specialists can provide support and be a resource CDI Queries need a response to be effective! 45

Metrics for Success Proposed Quarterly Goals –Query Response Rate –Case Mix Index –Increased SOI/ROM –Mortality Index –UHC Metrics 46

Questions?? 47