Health Information Management

Q&A: Chart reviews for new CDI specialists

CDI Strategies, April 30, 2015

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Q: Do you have any advice or guidance on how to conduct chart reviews for beginners in CDI? I am looking for specific strategies and approaches that might help our program, such as viewing labs first, or looking at emergency room (ER) notes, or history and physical notes (H&P)?

A: New CDI specialists travel a steep learning curve. There are so many components to master like regulatory guidelines, reimbursement, and even clinical, pathophysiology, and pharmacology. Nurses often specialize in a certain clinical area. Then, suddenly, as a new CDI staff member, you might need to review a record of a patient in entirely different specialty and find missing or undocumented diagnoses.

The record review is the central component of what CDI specialists do. I can only tell you what has worked for me, but my advice is, once you find what works for you, stick to the plan. I find that when I jump around a record in a disorganized fashion, I tend to miss important pieces of the puzzle.

The first thing I look at is the physician order for admission. I want to see where the patient was admitted from, for example, direct admission, same day surgery, ER, observation, clinic, etc. I want to review this to ensure I have an adequate order, specifying inpatient admission and why it was necessary, as stated by the physician.

From there, I go to the first piece of documentation, which is usually the ER physician record. This record gives me the backstory, the initial labs and diagnostics, and a description of the patient when he or she was first seen. If there seems to be conflicting data, or if I have a specific concern, I will review the ER nursing notes or emergency medical technician reports at that time.

Then, I move to the physician’s H&P. I want see if the two match, or if there is a conflict. I check to make sure the physician documented the clinical indicators which support the diagnoses.

After the H&P, I usually move to additional labs and diagnostic study results, mainly because I want to ensure I have support (clinical indicators for the diagnoses, and note any values or interpretations of concern to support any missing diagnoses, present on admission status, etc. After the labs, I review all the progress notes, consults, etc.

Then, I return to the orders. I check for orders for medications without an identified indication. I look for treatments or tests that might indicate a missing diagnosis. I see if the orders support identified diagnoses

After the orders, I go to the documentation of ancillary staff, such as nursing admission assessments, nursing notes, physical therapy, occupational therapy, speech, dietician notes, case management notes, etc. The notes from these professionals often assist in understanding the patient’s baseline conditions, and often help us to identify any secondary diagnoses not mentioned in the provider’s initial assessment.

Review the medication history and compare it with what the physician ordered for the hospital stay. What is new? What is not ordered? What has been changed? Any changed dosage or route may indicate a chronic condition that is now acute.

If your patient went to the operating room, review both the anesthesia record and the operation notes. The anesthesia pre-operation assessment may indicate secondary diagnoses not mentioned by the surgeon. The anesthesia intraoperative record will indicate medications and treatments administered in the operating room. Often, this is my first indication of possible complications. Then I review the operation notes, making sure the planned procedure matches the actual procedure performed, and, if not, I need to find out why. I also check if the pre-operative diagnosis matches the post-operative diagnosis and, if not, again I need to find out why.

At this point you should have a pretty good understanding of the patient’s condition and plan. I note any discrepancies, conflicting documentation, and possible missing diagnoses or present on admission issues along the way. Then, I can start the process of drafting queries as needed.

Now, for a repeat review, I follow my notes. If my notes are organized, I can identify what I have looked at and what is pending. When I return to the record, I can quickly identify where I left off and start with pending labs, new progress notes, etc.

As you start this process, do not get discouraged if you miss pieces. There are a number of ways to improve your skills. One great method when training, if you have a mentor or preceptor with you, is for both of you to review the record separately, and then compare answers. Look at how your co-workers “attack” the record review, and learn from their best practices.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.



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