Health Information Management

Tool: Send physician documentation kudos straight to the top

CDI Strategies, November 26, 2009

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At St. Mary’s Hospital in Passaic, NJ, Melanie Halpern, RN-BC, MBA, CCDS, clinical documentation specialist, helped develop a “good documentation” letter to congratulate physicians on their documentation efforts, complete with an “A+” graphic in the upper right-hand corner (visit ACDIS Forms & Tools Library to download the document.)

 

“We chuckled at the “A+” but it's turning out to have a beneficial effect,” says Halpern, who adds that physician documentation in the medical record should meet the basic elements of good clinical documentation as outlined in AHIMA practice brief “Managing an Effective Query Process,” issued on October, 2008. These include the following elements:

 

  • legibility
  • completeness
  • clarity
  • consistency
  • precision 

After the CDI specialist leaves the ‘good documentation’ letter for the physician, they e-mail the vice president of medical affairs (without disclosing patient identifiers) and describe what in the chart was exemplary, Halpern says. Here are two examples of e-mails sent to administrators:

 

1.      "FYI, I bestowed the ‘good clinical documentation’ letter to Dr. XXX, acknowledging his efforts (and the multidisciplinary consultants on the case) in the written documentation noted on a complicated, non-compliant patient with multi-system problems, admitted for aggressive treatment of a gangrenous below knee amputation. Surgery, renal, and ID have been providing excellent collaboration on the case."

2.      "I wanted you to know I placed my first ‘good documentation’ letter on the chart of Dr. YYY. The patient’s admitting diagnosis was pneumonia (94-year-old female on hospital unit X), and with excellent evaluation and management of clinical indicators and consultations, the severity of illness and co-morbidities were further described to include sepsis/metabolic encephalopathy and aspiration pneumonia."

 

“We thought it was important to recognize the consultants (and other providers) in the e-mail to administration because we want to endorse their documentation efforts. Despite my worry that it may set us up for legal problems, our administration felt the CDI staff
commented on the quality of documentation, not the quality of direct patient care. So, we currently incorporate this practice and probably post one or two letters per month,” Halpern says.



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