CDI specialists often underestimate the importance of the dictated history and physical (H&P) and progress notes when reviewing the medical record, according to Kate Green, RHIT, clinical quality specialist with Webmedx in Atlanta, GA. Many times it’s because the notes are hand-written, illegible, and difficult to search.
Webmedx is currently developing a query process that takes the diagnoses from the patient’s H&P, matches them to a working MS-DRG, and estimates the patient’s length of stay based on that data. The company can then generate a report and transmit it to the CDI specialist or utilization reviewer when he or she comes in the next morning to start their work. “We’re trying to give them a place to start on day one of the admission before the hospital starts with tests and procedures,” Green says.
These reports are based on the data contained in the transcribed H&P and progress notes, and include the name of the dictating physician and patient’s location in the facility. The automation allows CDI specialist to start their day earlier and leave queries for physicians they might otherwise miss. Text searches of the transcribed reports allow CDI specialists to identify unspecified diagnoses like unspecified anemia.
This process allows CDI specialists to more readily identify patients with a current diagnosis or past history of AMI, heart failure, or pneumonia, for example. It’s also of enormous benefit to hospitals that implement quality (aka, core) measures documentation into their chart review duties
“It identifies those patients with those (core measures) diagnoses so that you can affect that documentation from day 1—for example, how long has it been since they’ve been on an antibiotic and what antibiotics they’ve been on,” Green says.
Green says using a dictated and searchable H&P for reviews allows CDI specialists to identify up to 50% more heart failure patients, particularly those who have had a past history of the diagnosis.
Even if you can’t afford an automated system, Green recommends the following best practices for reviewing the H&P/progress notes and improving physician documentation:
- Embrace uncertainty. Initial dictation is often cloudy because physicians don’t always have the answers. Encourage them to document probable or suspected diagnoses early in the stay. “They can make an educated guess, and that may be good thing,” Green says. “It gets them thinking on day 1 and puts a more accurate slant on things.”
- Review the H&P. Take a quick look at the H&P at the outset of the patient’s stay. Make sure the physician’s progress notes reflect any revisions since the H&P was dictated
- Have physicians dictate their progress notes. Ask your hospital to invest in transcription or a speech-recognition service. Once they’re in an electronic system, the H&P and progress notes can be read and searched very easily. CDI specialists can use them to look for diagnoses, or for important elements like labs ordered, medications, and treatments.
“You get away from those progress notes that are illegible and just not up to par, and they can be reviewed more quickly easily if they’re in an electronic form,” Green says. “There’s so much information locked up in the dictated H&P.”
