Anatomy of a Medical Record




Just like a roadmap or if you use a map direction app such as MapQuest or Waze, one needs a start and end point. The same principle or concept applies to the medical record. There is a definite starting and ending point for a medical record, whether inpatient, observation, office visit, or ED to name just a few settings. Let’s focus upon hospitalization…More than half of patients are admitted to the hospital from the ED so that for all intents and purposes is the starting point. As a CDI professional, that is the first place to begin the chart review. If there is ambulance run sheet documentation in the record, this is also important to review as this documentation will offer a true clinical picture of the patient in any case, the CDI staffer should be looking for the answer to the questions of what did the patient look like, what is wrong with the patient, how did the patient present clinically. In other words, what is the clinical severity of the patient, the severity of the patient’s signs and symptoms. You will find this documentation in the History of Present Illness of both the ED and the H & P for admission. Really take the time to review each of these. There are eight elements of the HPI- a description of the development of the patient's present illness. The HPI is a chronological description of the progression of the patient's present illness from the first sign and symptom to the present. The HPI is where medical necessity hospitalization beings, the prism through which medical necessity is viewed. There must be a minimum of 4 elements of the HPI for any chance of the patient story being accurately reported, reflected, described, told, and depicted. If there is not a good story told after reviewing, this is where CDI can go back to the physician and seek additional information. This is a definite teaching opportunity for the CDI to educate and share best practices of documentation with the physician or NP/PA, whatever the case in the interest of continuous quality improvement in documentation. A query certainly won’t do with a situation like this. Remember, case management and utilization review/utilization management and physician advisors are dependent upon the quality and completeness of provider documentation. They are looking at the same documentation the CDI staff is reviewing, just from a different lens as my colleague Dr. John Zelem so eloquently states.


So now we have the HPI reviewed, of I do not want to forget the important CC or Chief Complaint. A chief complaint is a patient statement of what is wrong with them, why did the seek out care, remember it needs to be in the patient’s own words. Keep in mind the CC is not a diagnosis, I see CCs of acute blood loss anemia, acute hypoxemic respiratory failure, aspiration pneumonia etc., these are not CCs, these are diagnoses. Generally speaking, the CC is a symptom or sign.


The next rest stop or point of interest in the road journey is the Physical Exam, specifically the Constitutional part of the exam. What did the patient look like when the provider walked into the room, what is the provider seeing? You will want to ensure there is a correlation between the statements made in the constitutional exam and the HPI, there should be a strong correlation with the diagnoses listed in the assessment and the description of the patient in the constitutional part of the exam. For instance, if the diagnoses that occasioned the admission is acute hypoxemic respiratory failure, it would be red flag for the auditors to clinically validate and deny the diagnosis if the constitutional state alert, oriented X 3 in no respiratory distress resting comfortably on bed talking to the nurses. Now, there are mitigating circumstances to consider in reviewing the documentation, something that helps explain clinically the disconnect such as alert, oriented in no acute distress, patient’s respiratory compromise due to COPD exacerbation is well managed on 5 liters of O2. Something to explain the lack of correlation. You also want to ensure a disconnect such as the following is addressed through seeking clarification with the provider: well, nourished well developed male resting in bed just finished polishing off a cheeseburger and fires appears comfortable. Then you see a diagnosis of protein calorie malnutrition listed in the assessment, other instances where you are offering the auditors a way to clinically challenge a diagnosis, a CC or MCC potentially. I refer to this as the T ball system, my colleague Dr. Jake Martin, came up with this analogy, we put the ball on the T and let the payer hit it out of the park. I see this scenario all the time. Another example is community acquired pneumonia in the assessment, yet the physical exam shows lungs CTA, no rhonchi or rales noted, vital signs are within normal limits, no temperature whatsoever. This is another opportunity to reach out to the provider and share the fact that documentation such as this leads to clinical validation denials, where payers second guess the physician’s clinical judgment and medical decision making. Approach the learning opportunity as not questioning the provider’s clinical judgment and medical decision making, instead helping the provider to capture and reflect his/her clinical judgment and medical decision making in the record through effective accurate and complete documentation.


Just a bit on the available labs and other diagnostic workup available to the provider at time of decision to hospitalize the patient in the first place or become available shortly thereafter. It is simply not enough to blow these into the documentation or just appear in the documentation. All relevant normal or abnormal workup results must be included in the assessment and plan of care as part of diagnosis reporting, how the lab values or other workup results factor into the provider’s clinical judgment in coming up with the diagnosis, either differential or certain diagnosis or symptom followed by provisional diagnoses. It simply is not enough from a denial’s avoidance perspective or communication of care perspective to merely list diagnoses in the assessment. In the event of a denial, the record will contain and outline the physician’s clinical judgment and thought process that can be captured and included in an appeals letter by quoting in the letter.


Lastly, the plan of care must be reasonable, rationale and congruent with the assessment, every order should be traceable back to the assessment, whether it be a provisional or definitive diagnosis A good rule of thumb or best practice is for the provider to list in the assessment each acute and clinically relevant chronic condition if pertinent for the reason for admission or hospitalization, include with each diagnosis the specific order or orders coinciding with the diagnosis. And I forgot to mention earlier that within the assessment, each acute condition or diagnosis must be traceable to the signs and symptoms as documented in the HPI and any clinical indicator or finding that the provider used in formulating a diagnosis, both acute and definitive. As I mentioned earlier it is simply not enough to include a laundry list of diagnoses in the assessment without reporting the provider’s clinical rationale and thought processes in arriving at the diagnosis.


Let me close with this thought: Without a solid, accurate, and complete patient clinical story clearly depicted by the physician beginning in the Emergency Department, progressing to the History & Physical, continuing in the progress notes and summarized in the Discharge Summary, all the diagnoses solidified by the CDI specialists is immaterial. Payers are bent on disputing and challenging specific diagnoses, the likes of sepsis, acute respiratory failure, acute metabolic encephalopathy, acute renal failure/tubular necrosis, to name just a few. It is not likely these denials will go away. CDI-Step up to the plate and begin the process of embracing and putting into play a holistic approach to chart review with the intent of actually improving the quality and completeness of the medical record as a communication tool.

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