We have all heard the saying “If it wasn’t documented, it wasn’t done” so it is safe to assume that we all understand the importance of the documentation we keep on our patients. It serves as a written history required for quality patient care and it validates the services we provide to prove to CMS and other payers.
But hospitals, physicians, and other healthcare providers still have difficulty staying within the lines of compliance for survey and reimbursement purposes.
The upcoming required utilization of the ICD-10 codes are expected to help this issue however its implementation is not allowed until October 2014. So what else can we do? Set up a solid clinical documentation program. It seems like an easy answer but most providers do not take enough time to see to its creation.

Recently I read a paper written by the American Health Information Management Association (AHIMA) that discussed  the Clinical Documentation Improvement (CDI) process and guidelines to set up an effective program. Though CDI is geared mainly towards an inpatient setting, I found that this can be useful information for any facility looking to improve their quality management programs for clinical documentation. These are the main areas that they speak to in the paper.

Set up policies.

Firstly, organizations need to set up the framework for their programs which means policies and procedures need to be created. My suggestion would be to sit down yourself and think of the processes it would take to complete documentation reviews from start to finish. As the leaders of our business, it is important that we understand how every aspect of our business works and that includes the documentation our clinicians submit. Usually the policies included would be roles, actual processes to complete reviews, and quality assurance methods. When creating these processes,  ensure you include roles, triggers (i.e. when does this review start?), and any associated regulations that may be considered in the process. After this it is a good idea to research best practices from credible sources. Find resources and apply it to your own organization. All healthcare providers are different but some have found efficient methods that you can use in your own practices. Find what works and use it! Lastly, I would sit down with other professionals in my field or organization and validate the policies I have created.

Implement a clarification process.

This can be different for all organization but the concept of clinical clarification is all the same. For inpatient facilities it is more commonly referred to as the query process where there is a wider range of providers for one patient. However, as an outpatient provider, it is just as important to verify and confirm a clinician’s documentation.

The clarification process is normally used in situations where an auditor finds that documentation does not match the services being rendered or clarifying a patient’s condition at the assessment. Because clinicians are often unclear, the clarification process happens more frequently than we would like. It is important that we set guidelines for clarifications such as the documentation of a clarification request and the communication thereafter, the required time frames, and the standard elements of a clarification.

Employ qualified and competent staff.

Now that you policies and procedures are in place, it is just as important to ensure your staff meet the role requirements you have defined. Due to the nature of clinical documentation reviews, the individuals who typically fill these roles are either nurses or health information specialists who have sufficient background in the healthcare field or coding. AHIMA describes the core competencies to include knowledge of coding concepts and medical terminology, ability to analyze a patient’s medical record, clinical knowledge, and knowledge of healthcare compliance. Though an organization can utilize one person to complete these reviews, I suggest having several people review documentation to ensure its completion.

Clinical documentation will continue to be a huge part of our profession so it is up to us to ensure we are clear, concise, and accurate. Besides reimbursement, the ultimate goal should be to ensure our patients our receiving the right care.

What other guidelines have worked for you?

If you found any of this information useful and want more details on how to create a great process, feel free to email me and I can give you a more in depth description.