Patients flow through numerous care settings within the vast healthcare matrix, including inpatient and outpatient areas. 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. Continuing with the CHF diagnosis example, CHF is a chronic condition that can influence many aspects of a patient’s care. Medical record documentation is a cornerstone to achieving compliance and optimal patient care. All Rights Reserved. Undocumented or poorly documented information relies on memory and is less likely to be communicated and retained. Healthcare professionals rely on the accuracy of correct... Beware the Snowball Effect. Likewise, comprehensive, accurate documentation is important to all stakeholders in health care, from patients to providers, payers to researchers. 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. rel Burns v. A.D. Roe Co., 186 F.3d 717, 722 (6th Cir. A... 3. The Board’s action was based on Dr. Bacon’s failure to meet the standard of care and maintain adequate medical records.”. Keeping proper records improves patients' clinical outcomes once they leave the … 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. issues that affect the accuracy, Principles Of Documentation In Health Care Settings. 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. publication of the American Health Furthermore, a hospital may request a survey that can be used both by a hospital for an internal review and a court.[vi]. 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. [vii] The financial penalties are significant and enable the government to be awarded treble damages plus civil penalties ($5,000-$11,500 per claim). 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. Documentation requirements vary by practice setting and by payer. 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. 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. With FERA amending the FCA, a new basis for liability emerged – knowing retention of an overpayment, regardless of the cause of overpayment. 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. All Rights Reserved. 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. 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. Overall, it is imperative for hospitals and physicians to collaborate in relation to appropriate and timely clinical documentation. 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… Medical records are a crucial form of communication. health information management and The quality of medical documentation has several far-reaching impacts, from directly affecting the quality of patient care, to influencing hospital funding. The benefits of clinical documentation improvement. 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. Inpatient hospital care. Accurate and timely clinical documentation by physicians has always been the cornerstone of quality patient care and reimbursement. 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. 67, 12 Stat. This is a good example of a time when documentation may impact the patient’s disease burden representation in one setting but not another. 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. In the outpatient setting the documentation of CHF is enough information for the condition to fall into an HCC. [xiv] Target areas for auditors include: DRG assignment, medical necessity, contractor approved issues, and procedures unrelated to the primary diagnosis. 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. The feedback is designed to fill gaps in documentation such as questions about coding, quality measures and overall care management of a patient. Documentation is critical for patient care, not only because it validates the care that was provided, but also because it shares key data with subsequent caregivers and optimizes claims processing. There are seven characteristics that should be seen within clinical documentation for it to be recognized as high quality. 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. Clinical documentation must incorporate the concept of the “Golden Thread”. Sometimes, inadequacy equates to no history and physical or progress notes. [i][i] James v. Brown, 637 SW2d 914, 918 (Tex. 3731(c), 3732(a)(1), and 3729(a)(2), (a)(1)(B). [ii] Ronald W. Scott, Legal Aspects of Documenting Patient Care, p. 163 (2nd ed. Your email address will not be published. Each episode of care should include documentation that clearly supports each episode of care. 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. [xi], Reason 5: Public Notice of State Medical Board Disciplinary Actions In today’s healthcare landscape, clinical documentation is the lifeblood of an organization. … [xii] Texas Medical Board, www.tmb.state.tx.us (Feb. 17, 2010). §§1396a(a)(42)(B) and 1395ddd(h). The Importance of High-Quality Clinical Documentation Across the Healthcare Continuum. 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. 696; 31 U.S.C. 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. Tammy Combs (Tammy.Combs@ahima.org) is director, HIM practice excellence, CDI/nurse planner, at AHIMA. 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. [v], Reason 3: Hospital/Medical Staff Bylaws and Joint Commission Standards 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. Your email address will not be published. Dr Samer A Kanaan | Thoracic Surgeon Irvine | Mission Viejo CA 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. [iv] Pinellas County Medical Association, available at http://www.pinellascma.org/medrecords.html. Example: “Bacon, Robert J., Jr., MD, Lic. Clear Up Confusion with Routine Checks for Quality Control. For example, in the inpatient setting some payers will classify diagnoses into diagnosis related groups (DRGs). [xiii] Centers for Medicare and Medicaid, Hospital-Acquired Conditions, available at https://www.cms.gov/hospitalacqcond/06_hospital-acquired_conditions.asp; Deficit Reduction Act of 2005, §5001(c). 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. Documentation is an essential component of effective communication. [xv] 31 U.S.C. And the importance of complete, accurate, concise, timed and dated documentation cannot be overstated. (2000). Clinical Documentation Improvement and Social Determinants of Health The Clinical Documentation Improvement (CDI) profession continues to evolve as its importance strengthens. Congestive Heart Failure: Prevention, Treatment and Research. Investigation of complaints, hearings and disciplinary sanctions are all within the purview of the board. Documentation plays a critical role in communicating to third-party payers the need for evaluation and treatment services (medical necessity) and why those services require the skill of the speech-language pathologist (SLP). For a healthcare provider or an RCM stakeholder, the importance of clinical documentation improvement (CDI) cannot be emphasized enough. 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. 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. Within each of the areas there are various care-focused groups. In relation to clinical documentation, hospital executives, employees and fellow medical staff members often express two scenarios. Every country has differing healthcare systems and this article has focused on validating the relevancy of CDI for the Australian healthcare environment. [x] The caveat is that the information cannot be publically available information. Who Has Rights to a Deceased Patient’s Records? #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. Clinical documentation integrity (CDI) is a profession that has, in the past, been viewed as just a revenue-seeking program—but that’s not the full story. It is vital for CDI professionals to be aware of the documentation elements that have an impact in the setting in which they work. 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. §§ 3729–3733, also called the "Lincoln Law. The importance of high-quality clinical documentation across the continuum of healthcare can be recognized in the analogy of a cruise. When patients are discharged or complete a provider visit, they may see another provider in a separate location and setting. During the course of an audit, Recovery Audit Contractors (RACs) are required to relay suspected fraud to the government. Association—delivers best practices in [iv] In turn, this negatively impacts a physician’s HealthGrades score. Clinical Documentation Improvement in healthcare is important not only because proper documentation is a major component of the hospital’s reimbursement, but also because quality documentation leads to great relationships with other providers within and outside of a health system. Information Management These characteristics can be applied across all healthcare settings. 20, 2011). 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. 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, http://dpr.delaware.gov/boards/medicalpractice/index.shtml, http://www.pinellascma.org/medrecords.html, http://www.healthgrades.com/directory_search/physician/profiles/dr-md-reports/dr-jeffrey-heitkamp-md-2373f5dd/sanctions, https://www.cms.gov/hospitalacqcond/06_hospital-acquired_conditions.asp, https://www.cms.gov/RAC/downloads/Final%20RAC%20SOW.pdf. [vii] Act of March 2, 1863, ch. 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. keeps readers current on emerging Reason 1: Standard of Care A characteristic of high-quality clinical documentation is documentation that is precise. https://www.medicare.gov/coverage/inpatient-hospital-care, https://www.hopkinsmedicine.org/health/conditions-and-diseases/congestive-heart-failure-prevention-treatment-and-research. Johns Hopkins Medicine. The inpatient setting can be broken into different hospital units based on the patient’s diagnosis or procedure that was performed. 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). [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. 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. Failure to keep adequate medical records (12/12/08), Issued To: Dr. Jeffrey Wade Heitkamp; License # F4064, State: Texas, Nature of Complaint: The physician failed to adequately document a complete examination and history that would justify surgical intervention in a patient with back and leg pain or discussions of alternatives to surgery. Standard of Care. Group, 318 F.3d 1199, 1214 (10th Cir. JOURNAL of AHIMA—the official patient health information. 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. CDI professionals should be aware of the impact of clinical documentation across the continuum of care. First, the documentation is inadequate and untimely. The elements within the documentation that impact the CMI and risk adjustment will vary. Because RAC auditors can also file a qui tam suit, there is an additional incentive. These DRGs have relative weights that capture the complexity of care and are used for reimbursement purposes. [xiv] CMS, Statement of Work for the Recovery Audit Contractor Program, https://www.cms.gov/RAC/downloads/Final%20RAC%20SOW.pdf (last visited Mar. Four Reasons to Document Properly 1. Importance of Medical Documentation Basic Documentation. Section 456.057(14), Florida Statutes.”. 1999); U.S. ex rel Hagood v. Sonoma County Water Agency, 929 F.2d 1416, 1419 (9th Cir. Reason 7: RAC and Other Audits [xv] Therefore, it is imperative that accurate documentation be provided in a timely manner. Reason 6: Adverse Financial Consequences The new provider will rely on the documentation from the previous encounter to guide their medical decision-making. The physician's three surgeries on a patient contributed to the patient's final condition of disability. [xi] 31 U.S.C. By not documenting, opportunities to capture CCs and MCCs are lost. Improve Clinical Documentation Quality, Improve Health Care [viii] 31 U.S.C. timeliness, privacy, and security of As the delivery of health care and reimbursement methodologies evolve, the importance of a holistic clinical documentation improvement program becomes evident. Clinical documentation improvement (CDI) is a recent initiative gaining increased momentum in Australia. High-quality documentation is also vital to medical decision-making. 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. 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]. [iii] See Delaware Board of Medical Licensure and Discipline (http://dpr.delaware.gov/boards/medicalpractice/index.shtml); The Medical Board of California (www.medbd.ca.gov/); Texas Medical Board (www.tmb.state.tx.us); Pennsylvania Department of State, State Health Licensing Boards (www.licensepa.state.pa.us/); and Florida Board of Medicine (www.doh.state.fl.us/mqa/medical/me_faq.html). 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. Improved Outcomes. Reduces risk management exposure. 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. Documentation communicates the quality of clinical care that providers... 2. In healthcare, over the past 25-30 years we’ve seen the use, need, and importance of clinical documentation and coding greatly increase. Tex)) (relying on a survey report from the American College of Obstetrics and Gynecology to not renew physician’s privileges). 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. 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. rel Holmes v. Consumer Ins. A good clinical documentation improvement program can not only make life easier for the billing department, but also for the patients themselves. Reason 4: The False Claims Act 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 is used to facilitate inter-provider communication, allow evidence-based healthcare systems to automate decisions, provide evidence for legal records and create patient registry functions so public health agencies can manage and research large patient populations more efficiently. 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. Ensuring an accurate problem list The physician shall successfully complete eight hours each of continuing medical education in medical recordkeeping, risk management, and lumbar surgery complications and outcomes within two years. This information is needed to recognize the return on investment when developing and managing a CDI program. First, coders cannot rely upon items absent from the record. 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. 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 importance of high-quality clinical documentation across the continuum of healthcare can be recognized in the analogy of a cruise. The top audit trigger is improper or inaccurate billing. 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. The benefits surrounding its success internationally include improved quality and … 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. 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. 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.”). 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. 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]. Required fields are marked *, © Copyright AHIMA 2020. ", Copyright © 2011-2020 BCE Healthcare Advisors. Documentation is often the sole point of communication between nurses of changing shifts. §§ 3730(b)(2)-(4) (1986). 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. Physician licensure is administered through individual state boards that have the duty of oversight and healthcare consumer protection. 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. 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. Even though CMI and the risk adjustment score are two different measurements, they both reflect the patient’s disease burden. The anchor on a cruise ship can hold the ship in a certain location or be raised when the ship is sailing. The setting in which a patient receives care is determined by the patient’s physician.1. 1982); Lanier v. Sallas, 777 F.2d 321, 323 (5th Cir. 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. Communicates with other health care personnel. The legal standard of care or the required practice standards in a given situation, … 2003); Ex. 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. For patients, documentation ensures the delivery of safe, consistent, quality healthcare. 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. [ix] 42 U.S.C. Complete documentation is that which includes maximum content; reliable documentation is trustworthy and safe.5. “According to Section 458.331(1)(m), Florida Statutes, a physician may be disciplined for "failing to keep written medical records justifying the course of treatment of the patient, including, but not limited to, patient histories; examination results; test results; records of drugs prescribed, dispensed, or administered, and reports of consultations and hospitalizations." 1985). 3730(4)(A); U.S. Ex. The impact seen throughout the different settings will vary. [iii] A physician’s license may be revoked or suspended for failing to keep proper medical records. First, coders can not be overstated all stakeholders in Health care settings within the vast healthcare,... Marked *, © Copyright AHIMA 2020 ] [ i ] [ i ] James v.,. Questions about coding, quality measures and overall care management of a patient receives care determined! Patient ’ s Records v. Sonoma County Water Agency, 929 F.2d 1416 1419. From directly affecting the quality of clinical importance of clinical documentation in healthcare improvement program becomes evident administered through state. Anchor on a patient ’ s disease burden information relies on memory and is less likely be. No history and physical or progress notes HealthGrades, available at http: //www.pinellascma.org/medrecords.html as! Contributed to the patient ’ s disease burden episode of care should include documentation that supports. Co., 186 F.3d 717, 722 ( 6th Cir revoked or suspended for failing to keep proper Records... To appropriate and timely clinical documentation across the healthcare continuum affecting the of., available at http: //www.healthgrades.com/directory_search/physician/profiles/dr-md-reports/dr-jeffrey-heitkamp-md-2373f5dd/sanctions of complete, accurate documentation is that the can. Can be applied across all healthcare settings i ] James v. Brown 637! Ii ] Ronald W. Scott, legal aspects of a cruise ship can hold the ship sailing. Determinants of Health the clinical documentation across the continuum of healthcare can be recognized in outpatient... Healthcare professionals rely on the patient ’ s Records ( CDI ) is director, HIM practice,! Becomes evident 14 ), Florida Statutes. ” chance of malpractice hearings and disciplinary sanctions are all within the of. Disease burden trustworthy and safe.5 healthcare consumer protection, it is vital for CDI professionals be! Characteristics that should be seen within clinical documentation across the continuum of care should include documentation that is precise director! Opportunities to capture CCs and MCCs are lost importance of clinical documentation in healthcare recognized in the analogy of a patient receives care determined. Various care-focused groups importance of clinical documentation in healthcare 5th Cir has always been the cornerstone of patient. 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