Subsequent Reviews
Our documentation integrity program has been in existence for 5 1/2 years. We are finding that we have more subsequent reviews every day than we have initial reviews and I am wondering if we need to re-think our schedule.
Would someone please share with me their review schedule for subsequent reviews?
Juanita B. Seel, RN
Supervisor Documentation Integrity
Greenville Memorial Hospital
Greenville, SC.
Would someone please share with me their review schedule for subsequent reviews?
Juanita B. Seel, RN
Supervisor Documentation Integrity
Greenville Memorial Hospital
Greenville, SC.
Comments
--Juan
initial review was missing CC and/or MCC or the LOS is greater than 5
days. Currently we only have 1 FTE CDI Specialist so it is difficult to
perform 2, 3 and 4th reviews. Our Medicare payer mix is 32% and
Medicare HMO payer mix is 18%.
Theresa Hall, RHIT, ACPAR
Director of HIM/HIPAA Privacy Officer
East Georgia Regional Medical Center
P. O. Box 1048
1499 Fair Road
Statesboro, GA 30458
T: 912-486-1761
F: 912-871-2388
theresa.hall@hma.com
if there is a query. We follow the next day, if that query is responsible
for changing the PDX (time sensitive), such as sepsis, etc. If it is a
routine follow up every 72 hours. We also work closely with Case Management
& Social Service to identify potential discharges to ensure our reviews are
completed. It works well for us.
Susan A. Klein, RN, C-CDI
Saint Peter's University Hospital
Director, Clinical Documentation Mgt
office: 732-339-7613
fax: 732-745-5944 (specify room B175)
pager: 732-651-4359
Subsequent reviews are handled in the following manner:
Open query, no CC/MCC - daily
Routine f/u - every 2-3 days depending on the case
Pt awaiting procedure - review day after proc scheduled to confirm and routine f/u afterward.
Trachs - no f/u reviews once patient has trach and/or PEG
Cases awaiting guardianship - every 1-2 wks if needed.
Pt who are in house longer than 2 weeks - CDS can use judgement.
We are not always successful getting our charts, but this schedule is our goal!
Deborah Dallen,RN
Clinical Documentation Coordinator
Albert Einstein Medical Center
Phila PA 19141
admission (not enough information on the chart until then) and then
decide when to look at it next. If it is an MVA who has everything i.e.
cc and mcc's then I may set it out for a week - because they will be in
ICU on the vent for that long. I think this is where our clinical
critical thinking comes into play. We have to be able to see what is
the best use of our time. If there is a patient who is going to
procedure - then I check them the day after the procedure to confirm
type of procedure and if any clarification needs completed. Pure
placement patients, I wait 4-5 days to look at them again.
Michelle Clyne, RN, BS
Clinical Documentation Improvement Specialist
Medical patients get reviewed daily for CC/MCCs and to make sure they didn't go to surgery. Surgical patients are also reviewed daily until they get an MCC, and then I might skip a few days, just going back to make sure they didn't go back to the OR for something else. I also will do a quick check of outpatients to make sure they don't actually meet IP criteria and would therefore need a CDMP review. I only stop completely when a patient is DRG 3 or 4.
My caseload this morning was 44, with 13 new reviews, and I was completely done in about five hours. But we are a specialty hospital, and I am the only CDS, so I see the same patients and the same dx over and over. If I have time on Monday, I sometimes do retrospective reviews for patients who came in and left over the weekend.
Linda Renee Brown, RN, CCRN
Clinical Documentation Specialist
Arizona Heart Hospital
Thank you again for your responses.
Nita Seel, RN
Supervisor Documentation Management
Greenville Memorial Hospital.
I would be very interested what you develop. We are a similar facility with similar staffing. If you don't post it here, would you please send me a copy?
Thanks,
Michelle Thimmesch, RN, MSN
Manager, Clinical Documentation Improvement
Via Christi Regional Medical Center
Wichita, KS
316-268-8570
I would also be interested in what you have developed. I too work in a 700+ bed teaching hospital with multiple medical facilities.
Kim Carr, RHIT, CCS
Core Measure and Clinical Documentation Improvement Manager
Care Management
Erlanger Medical Center
975 East Third Street
Chattanooga, TN 37403
phone # 423-778-4225
email-kimberly.carr@erlanger.org
Life isn't about how to Survive the Storm, but how to Dance in the rain!!!!
Do the CDIS in put into a computer data base? Or do you have secretarial
help to do that portion. We do about 15-20 reviews per day. I am
wondering how you complete 35 per day. Maybe we need to change the way
we are reviewing.
Karen Beal, RN, BSN, CCRN
Clinical Documentation Improvement Specialist
Huntington Hospital
100 W. California Blvd.
Pasadena, CA 91109
626-397-2024
Fax 626-397-2904
karen.beal@huntingtonhospital.com
on our ortho floor). We just met and our goal is to not crank out so
many reviews (our team is hourly so they are getting it done in 8
hours). We are going to focus on the quality of the review instead of
the quantity, hoping to find more query opportunities and to improve
chart documentation. We are going to try 23-25 reviews per day. I am
hoping if we see less cases a day, but make more impact on the ones we
touch, we will have a greater return.
Sincerely,
Karen A. Johnson
entered into the computer as the chart is reviewed. Each Doc Spec has their own
lap top. We do in-depth reviews....and still accomplish that many reviews.
However, I am concerned about missing some prime opportunities and this is
why I was asking about subsequent reviews. In some instances, it is the
subsequent reviews that offer the most opportunity for clarification. I do not
want to put the subsequent review schedule so far out that we miss these
opportunities. I have developed a "Trial review schedule" with the help of
the Doc Specialist and we hope this will give us more time daily to review
medical records.
charts? How many beds is your facility?