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Institute shadowing practices to improve clinical documentation

HIM Connection, May 23, 2006

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Institute shadowing practices to improve clinical documentation

Shadowing is a practice that you can integrate into the physician learning process. It pairs a nonphysician clinician/documentation expert with a physician for one day of patient care. It should occur after physicians receive initial classroom training in CDI and understand basic concepts in both the hospital and office settings. Shadowing is a practical application that you can use effectively with physicians, as opposed to nonphysician clinicians.

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 requires 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. Institute shadowing using the following steps:

1. Choose appropriate individuals to perform the shadowing.
   The selection of appropriate individuals to shadow physicians is an essential element in the success of the program. Those individuals 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 detail oriented and have excellent investigative skills. Moreover, they must be skilled negotiators and enjoy the respect of the physicians in your organization.

2. Identify physicians willing to participate in the process.
   You may have some leaders or early adopters from other programs you have organized in the past. If so, you may want to approach these physicians to participate.

3. Test the process with a few select physicians.
   Once you have identified a few physicians willing to be shadowed, you will want to test the process. Work with a few physicians initially to define your process because shadowing never works exactly the same way in every organization.

4. Define the method that will work for your organization.
   Use the test run to define your process. For example, is shadowing done for a full day or only part of a day in your organization? When can you provide feedback to the physician being shadowed-right after the patient's been seen, or at the end of the day? What specific information do physicians in your organization want to focus on? Some of these responses will be based on the type of organization and whether physicians are employed at the facility or based in the community.

5. Create a "hook" to persuade physicians to participate.
   Shadowing is not an activity that you can force on physicians. In fact, if you are very selective about whom you ask to participate, physicians may actually volunteer. The best scenario for your operation is to have physicians come to you and ask for your assistance. The results can be extremely helpful, not only to the organization but also to the physician. 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.

6. Invite other physicians to participate.
   Remember that shadowing should not be mandatory for any physicians. They must want to participate. Without their support, the process will not be valuable. As noted above, you may want to explain to physicians that the shadowing activity is available to them and that the process involves feedback on documentation that may impact hospital as well as professional reimbursement. You will also want to note that this service is limited, and given the scarcity of individuals who are qualified to shadow the physicians, this will probably be a true statement.

Editor's Note: This article was excerpted from HCPro, Inc.'s book Guide to Inpatient Clinical Documentation: Strategies to Ensure Compliance and Correct Reimbursement, written by Ruthann Russo, JD, MPH, RHIT. For more information or to order go to www.hcpromarketplace.com or call 877/727-1728.

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