Health Information Management

Strategy: Multi-disciplinary documentation helps solve CHF problems

CDI Strategies, June 11, 2009

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During the May 28 ACDIS quarterly conference call, one member stated that she is having a difficult time with documentation of congestive heart failure (CHF). Her physicians aren’t documenting specificity or acuity, including systolic vs. diastolic, chronic, acute on chronic, etc.  Kimberly Richert, RN, lead clinical documentation specialist for Florida-based Morton Plant Mease Healthcare says her facility used to have the same problem, which affected more than one department.
 
The facility has an evidence based measures (EBM) team made up entirely of RN’s.  Both the EBM and the CDI teams asked the same questions for CHF. Even though the CDI specialist’s questions were a little more detailed, neither team’s queries were working very well, Richert says.
 
Mease Countryside and Mease Dunedin hospitals pilot-tested the EBM progress notes for their queries.  The two facilities solved the query problem by creating a progress note using input from both the EBM and CDI departments.
 
“This sheet answers the EBM team questions and ours all together,” Richert says. “Due to the measures that must be met for CHF, and how the [physicians] provide treatment, these questions must be answered completely.”
 
According to Richert the progress note works great for capturing information up front. It’s used for coding as well as quality measurement purposes and is also considered a permanent part of the medical record.
 
“Either our CDS team leaves the sheet or the EBM team leaves them on the chart.” Either way the new process helps provide documentation answers, she says.
 
ACDIS members can download the form by visiting the Forms & Tools section of the Web site.



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