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Try elbow-to-elbow education for documentation improvement

HIM Connection, September 23, 2003

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TOPIC: Try elbow-to-elbow education for documentation improvement

To train non-physician clinicians to identify possible opportunities for improved clinical documentation, pair them up with experts in documentation and coding in an "elbow-to-elbow" review of inpatient medical records on the nursing unit. You can implement elbow-to-elbow training using the following steps:

--Use the daily census to identify all patients for review. First, identify the resource that will allow you to track all patients for documentation review. This is most commonly the inpatient census. This tool should be used so that all cases that are admitted are reviewed.

--Conduct nursing reviews by nursing unit. Documentation review by nursing unit is the most efficient methodology for two reasons: First, inpatient census is generally categorized by nursing units. Second, clinicians performing reviews will most likely be stationed at distinct nursing units.

--Review each patient case initially and record all necessary data elements. Initially, the process should involve the documentation specialist who reviews inpatient records and shares findings with the clinicians on the unit. Beginning the process like this allows the documentation specialist to get a handle on the overall documentation challenges in the unit and to determine the specific strategy for improvement by unit. Because documentation review is usually a new part of the clinician's job, a strategy that includes the documentation specialist, is an effective way to begin the clinical documentation improvement review process.

--Include the following as the initial data elements to review and record:

1. Patient Name/medical record number
2. Date of admission
3. DRG assignment
4. Relative weight
5. Average length of stay (ALOS)
6. Type of concurrent query (if asked)

--Conduct a second review of the physician's documentation. Once the initial data elements are recorded, and if a concurrent query has been asked of the physician, a second review should occur to determine whether the physician has added the necessary documentation.

--Add additional data elements to the original list; they should include the new answers to any of the above-listed initial data elements.

Additionally, feedback to the clinician should be available on a case-by-case basis during the initial set of reviews. As they continue to work together, the specialist can begin to shift responsibility of the reviews over to the clinician. After two or three weeks, the clinician should be performing the reviews with the documentation specialist providing only the oversight and feedback. Eventually, when the clinician is conducting the reviews independently, the documentation specialist can perform documentation audits on a monthly or quarterly basis as a continuous learning opportunity for the clinician.

This week's HIM Connection was adapted from an excerpt of the book, "Guide to Inpatient Clinical Documentation Improvement," by Ruthann Russo, JD, MPH, RHIT. Click Here for more information or to order. Check out the Editor's Choice section below for a kit for training coders on the 2004 ICD-9-CM codes.

Sincerely,

Kate Alvarez
Editorial Assistant
kalvarez@hcpro.com

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