Does Reimbursement Focused Behavior Drive Process Improvement?
A major challenge of current clinical documentation improvement processes is the undivided focus upon reimbursement as the primary outcome, something undisputable with a clear review of present day Key Performance Indicators. The expression and reporting of the clinical truth in the record beginning with the Emergency Room Documentation, transitioning into the H & P and continuing with the consultant reports and progress notes culminating in the discharge summary is paramount to effective communication of patient care. Often the CDI profession references and points to the fact CDI helps tells the patient story, thereby impacting quality, safety, and reimbursement. I fully support the latter as a byproduct of solid effective contextually accurate clinical documentation; however, I question and downplay the effectiveness of CDI truly impacting positive change in quality and safety through the diagnosis query clarification process. Continue reading and you will clearly see my point.
Getting to the Crux of Documentation
A quick read of this article from Urology Times on January 10th highlights the real pitfalls of focusing primarily upon reimbursement, that is overlooking other crucial elements of healthcare whose effectiveness is predicated upon and directly proportional to the accuracy completeness and spatial nature of the clinical documentation throughout the record. The medical record serves as a communication tool for physicians and other healthcare providers with one important function often overlooked by clinical documentation improvement specialists, that of a medico legal document. CDI is so preoccupied with securing diagnoses as monitored, measured and reported by Key Performance Indicators centered on reimbursement that quite frankly we miss an opportunity to devote sufficient energies in effectively communicating the patient’s care. Medio-legal documentation standards encompass and incorporate a higher level and degree of accountability for physicians to adhere to and master, exercising solid documentation principles extending far beyond diagnoses reporting that CDI emphasizes and hones in on in every chart review. The Doctor’s Company, a physician malpractice insurance company, provides practical useful medical record documentation principles and standards to alleviate and minimize medico-legal compliance risk. I am sharing two links to pertinent documentation related articles that are must reads for all clinical documentation improvement specialists.
and Accurate Medical Record Documentation
Now let’s return to the Urology Times Article titled How Incidental Radiology Findings Can Lead to Malpractice Litigation.