1. Clinical Documentation Improvement Program In-Patient Status
University of New Mexico Hospital
Alethea Martinez, RN, MSN, MSC
HIM Director Clinical Documentation Improvement

2. From the Clinical Documentation Improvement Department
Welcome
From the Clinical Documentation Improvement Department

3. Why Documentation Matters:
Quality Management Profiling
Joint Commission
Core Measures
State Reporting
Supports
DRG & Coding Assignment…
Severity of
Illness and Risk of Mortality
More accurate
Case Mix Index
Links with Compliance Program
Key Driver:
DOCUMENTATION
Helps justify LOS inconsistencies
RAC Audits-CMS recovery audit program
Appropriate Reimbursement
Supports
Medical Necessity/ Denials Reduction

4. What is Your role? you are here to treat the patient.
The most important thing to remember is
you are here to treat the patient.
Nobody else can coordinate and direct the medical care of the patients like you have been trained to do.
The CDI role is to assure accurate documentation is in the record to support the medical diagnosis, the medical necessity of the care being given, and obtaining the most complete record to meet the Centers for Medicare & Medicaid Services guidelines.

5. Some history……
In case you haven’t heard, you are only as good as the patients you treat. Over the past few years the Centers for Medicare and Medicaid Services (CMS) has released information about how well hospitals meet certain criteria for patient care and satisfaction and it is posted on the internet at
CMS is also making information about hospitals and physicians public through their websites hospital compare and now physician compare
The safety indicators, clinical quality and patient experience are listed. This is an ongoing process.
Where does this information come from? The coding and billing of patients seen by you supply the data for these criteria and it also creates your physician profile.
Think about it –
If you handle more complex patients, don’t you want to get that credit and recognition?

6. How documentation can impact the Length of Stay
Patient presents from nursing home with pneumonia.
Pneumonia (simple)
With no comorbid conditions
DRG SOI 1 ROM 1 R.W GLOS 2.7 days
With comorbid condition of chronic systolic heart failure
DRG SOI 2 ROM 2 R.W GLOS 3.4 days
With major comorbid condition of acute respiratory failure
DRG SOI 3 ROM 3 R.W GLOS 4.5days
Pneumonia due to gram negative bacteria (or complex pneumonia i.e. aspiration)
DRG SOI 1 ROM R.W GLOS 3.4 days
DRG SOI 2, ROM 2 R.W GLOS 4.5 days
DRG SOI 3 ROM 2 R.W GLOS 5.7 days

7. How documentation paints the picture we see
Symptom
Lab Value
No Dx
Lab Value
Vital Sign
“75y/o chronic lunger w fever, leukocytosis, SOB with hypoxia and altered mental status.”
How about: “75 y/o with COPD exacerbation with acute and chronic hypoxic respiratory failure; now presenting with pneumonia, probably Gram negative in view of age, and likely a gram negative empyema, probable severe sepsis, with acute septic encephalopathy as well.”
Clinical Finding
DRG 204 Respiratory Signs and Symptoms
SOI ROM R. W GLOS days CC
MCC
MCC
Principal Dx
MCC
MCC
DRG Sepsis w/o MV 96+ hours w/MCC
SOI 4 ROM 4 R.W GLOS 4.9
Same patient, same treatment, may “ look “ different with more complete documentation and the acuity of the actual care given will be reflected in the code assigned after discharge

8. Our goal is to have the most complete record at the time of discharge.
Our Process
Daily review of the information available in Cerner. (from ER, H/P, Anesthesiology, progress notes, OP notes, tests, labs, x-rays, CT’s)
With this information and the specific software, we identify gaps in documentation . With complete documentation we will have an accurate reflection of the acuity of care given for each hospital admit.
Our goal is to have the most complete record at the time of discharge.
To be sure each comorbid condition (CC) or major comorbid condition (MCC) is identified and documented
This can get challenging with the shorter lengths of stay

9. How do you know when additional documentation is needed ?

10. Our expectation is that any Clinical Documentation Clarification or Coder Query will be addressed within 48HOURS –
A clarification is delivered to your
Please Document your response in the progress notes and discharge summary
If you need to communicate with the CDS you can respond to the message with any additional information

11. The most important aspect is to have the accurate information IN THE BODY OF THE MEDICAL RECORD to support any future audits regarding the care provided.
We try to capture the most complete picture of our patients’ condition during the hospitalization.
As part of the team any feedback and suggestions are appreciated

12. Now what do you do????
Include the information in your daily progress notes along with the ongoing status and you’re done!
Include all medical diagnoses treated or monitored in the discharge summary to support the treatment rendered through the hospital stay
Carry the information forward and verify any notes that are copied and pasted forward are accurate for documenting continuity of care.
the discharge summary should be a synopsis of the patient's condition(s) and treatments(s) received from admission to the time of release

13. 2 Simple things to remember!
If you treat it,
DIAGNOSE IT!
If you are monitoring it, DIAGNOSE IT!

14. We are here for You!

15. Our Staff 14 UNMH CDS’s 1 CDS SRMC
Questions?

17. Thank you for working with us to take care of our patients
Health is the thing that makes you feel that NOW is the
best time of the year
Franklin P. Adams