Case Management

Ensuring clear and concise documentation critical for case managers

Case Management Insider, April 14, 2015

Proper documentation is critical when it comes to supporting medical necessity and providing quality patient care.

Case managers can be a crucial component when it comes ensuring documentation supports medical necessity, says Glenn Krauss, BBA, RHIA, CCS, CCSP, CPUR, FCS, PCS, C-CDI, CCDS, C-DAM, executive director of the Foundation for Physician Documentation Integrity in Burlington, Vermont.
 
Case managers are in the perfect spot to identify, recognize, and help improve incomplete and insufficient clinical documentation, Krauss says. The best way to do this is to form a collaborative partnership with physician advisors and clinical documentation improvement (CDI) specialists to initiate meaningful change.
 
Case managers can help physicians improve documentation by making a compelling argument for physician advisors to learn more about CDI, Krauss says. The physician advisor can then carry that message to CDI specialists to raise their awareness and understanding of the need for complete, concise, and effective clinical documentation. Documentation should also ensure that the right care was delivered at the right time, for the right reason, in the right venue, with the right information.
 
A team approach between case managers, utilization review/management staff, and CDI specialists can help improve clinical documentation. This group of workforce members can encourage the physician advisor to intervene when documentation in the history and physical and daily progress notes doesn’t accurately capture the physician’s clinical judgment, medical decision making, thought processes, and problem-solving ability.
 
For case managers to spur changes, they have to recognize good documentation.
 
According to Krauss, medical record documentation should:
  • Accurately tell and retell the patient story in specific detail
  • Completely and concisely communicate the patient’s care needs by accurately describing his or her clinical status (including specific diagnoses), comorbidities, and past medical history in relation to his or her current care
  • Describe plans for current and future care and identify a time frame for follow-up
  • Promote cost-effective discharge planning and chronic care coordination
  • Include detailed information about physician clinical judgment, medical decision-making, thought processes, analytical skills, and problem-solving
  • Include information that allows for accurate assessment, planning, implementation, continuity, and evaluation of quality medical care
  • Clearly establish and support medical necessity and level of care for all services or supplies provided or ordered at a specified time
  • Adequately support the goals and objectives of the physician advisors, case managers, discharge planners, and utilization review staff members
 
In addition, ensure medical record documentation accurately answers to the following questions:
  • Who is performing the service?
  • What type of services are performed and why?
  • How many services are performed and why?
  • What are the quantities of services performed?
  • What is the place of service?
  • When is the date of service?
Knowing more about the medical record may help case managers spot deficits in the medical documentation. They can then work with CDI and the physician advisor to ensure that coders will have the most detailed information possible to assign codes, and clinicians will have the best information possible to guide patient care.

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