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Tip: Uncover the hidden clues in physician documentation

CDI Strategies, January 10, 2008

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Clinical documentation improvement (CDI) specialists know that there's much more to a patient's story than just his or her discharge summary. But CDI specialists sometimes rely too heavily on that part of the record to the exclusion of others when reviewing a case, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, an independent consultant located in Maryville, TN.

If they don't perform a thorough record review, a CDI specialist can fail to catch DRG-changing CCs and MCCs (e.g., chronic respiratory failure). Or they may overlook clues that can change a simple pneumonia to a gram-negative pneumonia, for example.

"There's more to reviewing a record than just arriving at a DRG--that's only half the battle," Krauss says. "A clinical documentation specialist has to use his or her clinical acumen and go through the record."

Consider the following plan of attack to conduct a thorough a record review, Krauss recommends:

1. Begin with the ambulance sheet. This allows you to formulate an initial picture of the patient's problem.
2. Move to the ED nursing notes/dictation. You'll often find documented services and medication administrations that can provide additional clinical clues.
3. Review the patient's history and physical and consult notes.
4. Review the physician's orders for clues and indications of clinical conditions that the physician is exploring or considering in the work-up of the patient.
5. Scan the labs and radiology reports for possible clinical conditions that guide and impact the physician's medical decision making.
6. Finish with the progress notes. "This gives you an idea of what the physician is thinking, and what clinical path he's going down," Krauss says. "Use these to formulate a query."

"Clinical documentation specialists have to understand what the physician is thinking, and know when he or she isn't giving us the information," he adds. "The last piece is assigning a DRG."

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