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TOPIC: Use a shadowing program to improve documentation

HIM Connection, December 23, 2003

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TOPIC: Use a shadowing program to improve documentation

Shadowing involves the pairing of a nonphysician clinician or documentation expert with a physician for a day of patient care. It can occur after physicians have been provided with initial classroom training in clinical documentation improvement and once they understand its basic concepts in both the hospital and office settings.

The documentation expert "shadows" the physician, and at the end of the day, the two practitioners compare notes on what should have been documented based on what the physician did for each patient. This practice provides a lot of feedback from the documentation expert to the physician, and can greatly benefit a physician who is open to receiving and using the feedback.

Use the following steps to implement your own shadowing program:

1. Choose the appropriate individuals to perform the shadowing. The documentation expert must be able to communicate with the physicians on a clinical level and must also understand the importance of complete and accurate documentation. They must be excellent negotiators and appreciate a good relationship with physicians in your organization.

2. Identify physicians willing to participate in the process. You want physicians who are natural leaders and who are eager to join in new ventures to participate in your shadowing exercises. They will be more likely to lead the way for other physicians.

3. Test the process with a few select physicians. Shadowing never works exactly the same way in every organization so initially work with a few physicians to define your process.

4. Define the method that works for your organization. Is shadowing done for a full day or only a half day in your organization? Can you provide feedback to the physician being shadowed right a way or should you do it at the end of the day? Some of these responses will be based on the type of organization you work for.

5. Create a "hook" to persuade physicians to participate in the program. You can't force this activity on your physicians. In fact, if you are very selective about whom you ask to participate, physicians may begin to request participation. It's best to have the physicians come to you.

6. Invite other physicians to participate. After you have the program off the ground, ask other physicians to join in. Remember that shadowing can't be mandatory, the doctors have to want to participate. Make it known to physicians that the shadowing process is available to them and could provide feedback that would benefit the hospital.

Be sure to tell the physicians that this opportunity is a scarce one-which will probably be the case, given the scarcity of qualified documentation experts to shadow the physicians. In a best-case scenario, physicians will come to you. If they do not, you may want to engage in some additional marketing activities. But chances are that the word of other physicians who have been involved in shadowing will increase demand for the service.

This HIM Connection was adapted from the book, "Guide to inpatient clinical documentation improvement: Strategies to ensure compliance and correct reimbursement," by Ruthann Russo, JD, MPH, RHIT.

Click here for more information or to order.

Kate Alvarez
Editorial Assistant
kalvarez@hcpro.com

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