1. Clinical Documentation Tool Box
Nora Blankenbecler – Director – Health Information Management, Mountain Empire Community College

2. Criteria for High Quality Clinical Documentation
Legibility
Reliable
Precise
Complete
Consistent
Clear
Timely
If it wasn’t documented – it didn’t happen!

3. – Legibility – HIPAA gives patients right to clarification

4. Reliable, Clear and Timely
Treatment provided without documented diagnosis
Vague/ambiguous documentation : Chest Pain vs GERD
Is there a working or final diagnosis documented?
Did the clinician document the reason for the diagnostic test?
Did the physician document the clinical significance of abnormal test result?
Clinical evidence for diagnosis
Sign off your records at the end of the encounter!

5. Precise, Complete and Consistent
The record is accurate, detailed and clinically appropriate.
More specific diagnosis appears to be supported
Is there a working and/or final diagnosis?
Is there a documented reason for tests?
Documentation deficiency – when the progress note of one physician is not consistent with the attending physician.
Here’s a tip: For Unstable Angina/Circulatory Disorder – Consider:
Document unstable angina and if pain is or isn’t controlled
Document the type of angina (Rest angina, New onset, Worsening Class III+
Note ECG findings
Include any positive diagnostic testing such as:
Stress Tests or CCTA
Chest pain/angina in the past 24 hours
Continuous cardiac monitoring

6. Documentation Requirements – If It Wasn’t Documented, It Didn’t Happen!
Complete and legible record
Documentation for each encounter should include;
Reason for the encounter, relevant history, exam and prior diagnostic test results; reports if applicable;
Assessment, clinical impression;
Plan for care; patient education/instructions
Date and legible identity of the provider; signature required;
Rationale for ordering diagnostic & other ancillary services should be documented or easily understood

7. Clinical Documentation Requirements
Past & present diagnoses should be accessible to the treating and/or consulting physician
Identify health risk factors
Patient’s progress, response to treatment, changes in treatment or revisions in diagnoses should be documented
Document any revisions to the plan of treatment
Services billed should be supported by medical record documentation; code correctly

8. Clinical Documentation Requirements
The medical record must contain information such as notes, documentation, records, reports, recordings, test results, assessments, etc.
Justify admission
Justify continued hospitalization
Support the diagnosis
Describe the patient’s progress and the patient’s response to medications
Describe the patient’s response to services such as interventions, care, treatments, etc.
All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.

9. Documentation Reminders – Critical Care
Critical Care (CPT first 30 – 74 minutes) Critical Care Services
Documentation must support the critical care E&M service
Document medical necessity of services with the total time the physician and/or hospital staff were engaged in active face-to face critical care of a critically ill or critically injured patient
Critical care services/the patient Critical care services/the patients condition warranted the type condition warranted the type and amount of services provided

10. Hospital Observation vs inpatient admission
You have a patient comes in the ED that is having a COPD exacerbation.  Patient has 02 sat of 91% on room air.  Patient has complaints of dyspnea that have continued to worsen and today she felt like she needed to come to the er. 
Same patient after all records had been scanned
Patient presents to ED with worsening dyspnea despite treatment of proair x 2 prior to arrival to ED and then xopenex and albuterol in ED.  Pt is using accessory muscles and having to sit in orthopneic position.  Patient cannot speak in complete sentences.  02 sat 91%ra
Second example would be the documentation that would justify inpatient admission.

11. Clinical Documentation is all about Relationships and Teamwork
It’s more than a process – It’s team work
Long term benefit is better data and improved research
You can’t do it alone!
Partner with a nurse with strong documentation knowledge
Ask the CDI specialist or HIM professional for advice
Encourage your organization to form a CDI “huddle” to discuss top twenty diagnosis and tips for documentation.
Make a “cheat sheet” for documentation you can share