We have been ask by our administration to come up with a way to grade how our hospitalists are documenting.Anything we could come up with would be very labor intensive. Any ideas?
We use 3m to track who we ask a query of and their response of lack thereof. We track by doctor asked and whether or not they responded. If someone else answers the query it is then that person that gets credit.. we assume their documentation is okay if we don't have to query. This is far from a perfect system, but it is a start. Amy
What about looking at one diagnosis (sepsis, pneumonia .. something in your top 5) for one quarter. Do a spread sheet with the account #, the DRG, the physician queried and the physician who answered, what the query was for, the final DRG etc... Make sure to run a month end report on that chosen DRG to log on the sheet the admissions and the physicians that didn't need a query to show how many admits had great documentation with a clearly supported DRG. If you needed to go up the chain of command to get a query answered - leave a column to show that too.
This isn't all inclusive answer to Hospitalist documentation but allows Admin to get a snap shot from CDI.
If Admin is truly committed to evaluating the Hospitalists documentation than set up a meeting with other departments who rely on the documentation (QA, CM Coding etc..) and brainstorm on what you could look at together.
Gail Marini MM, RN, CCS Manager Clinical Documentation South Shore Hospital 55 Fogg Road, South Weymouth, MA 02190 Phone: 781-624-8413 To page call: (781)-624-8123, pager # 7757 http://www.southshorehospital.org
I do a monthly "Doc Stars" report. We record a QNN -query not needed- each time we review a new case and find the appropriate documentation for:
1) Diabetes
2) Heart Failure
3) HTN
4) Acute blood loss anemia
5) Present on admission pressure ulcer
The monthly report goes to the office manager for our two main hospitalist groups, the Residents Coordinators at the school, is reported to admin, and is posted on a bulletin board in the physician's dictation room. Physicians are very competitive and they enjoy positive reinforcement. I know it sounds silly, but my doctors love their stars.
We are also working on giving our hospitalist groups feedback about pressure ulcers documentation (POA status) for the last year.
Vanessa Falkoff RN Clinical Documentation Coordinator University Medical Center Las Vegas, NV vanessa.falkoff@umcsn.com office 702-383-7322 cell 702-204-0054
If your facility uses Meditech, have a report generated from the nurses admission assessment, using the admission weight and the calculation of the BMI. From this report, the Dieticians have set parameters they use for the BMI, which helps them select which patients they need to complete an assessment on. From this list the Dieticians document the BMI in the nutrition assessment.
So together with this documentation by the dietician and the physician documentation of obesity, malnutrition or any signs of questionable malnutrition, you can either query or capture the BMI for coding.
Vanessa, that is a fantastic idea. I've always wondered how we could show that we're still making an impact after the physicians have been educated and the CMI has stabilized, and gathering data that proves what we've taught is terrific.
Renee
Linda Renee Brown, RN, CCDS, CDIP, CCS
[Boy, does it hurt having to let the CCRN go after 24 yrs]
Have you considered pulling data from UB04 that indicate if DRG has cc or MCC? You could then calculate which MDs have the most MCC/CCs by DRG. You could choose top 5-10 DRGs per MD group and line graph the results. Or is this the labor intensive approach you mentioned?
Comments
Amy
your top 5) for one quarter. Do a spread sheet with the account #, the
DRG, the physician queried and the physician who answered, what the query
was for, the final DRG etc... Make sure to run a month end report on
that chosen DRG to log on the sheet the admissions and the physicians that
didn't need a query to show how many admits had great documentation with a
clearly supported DRG.
If you needed to go up the chain of command to get a query answered -
leave a column to show that too.
This isn't all inclusive answer to Hospitalist documentation but allows
Admin to get a snap shot from CDI.
If Admin is truly committed to evaluating the Hospitalists documentation
than set up a meeting with other departments who rely on the documentation
(QA, CM Coding etc..) and brainstorm on what you could look at together.
Gail Marini MM, RN, CCS
Manager Clinical Documentation
South Shore Hospital
55 Fogg Road, South Weymouth, MA 02190
Phone: 781-624-8413
To page call: (781)-624-8123, pager # 7757
http://www.southshorehospital.org
I do a monthly "Doc Stars" report. We record a QNN -query not needed-
each time we review a new case and find the appropriate documentation
for:
1) Diabetes
2) Heart Failure
3) HTN
4) Acute blood loss anemia
5) Present on admission pressure ulcer
The monthly report goes to the office manager for our two main
hospitalist groups, the Residents Coordinators at the school, is
reported to admin, and is posted on a bulletin board in the physician's
dictation room. Physicians are very competitive and they enjoy positive
reinforcement. I know it sounds silly, but my doctors love their stars.
We are also working on giving our hospitalist groups feedback about
pressure ulcers documentation (POA status) for the last year.
Vanessa Falkoff RN
Clinical Documentation Coordinator
University Medical Center
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
cell 702-204-0054
Gail Marini MM, RN, CCS
Manager Clinical Documentation
South Shore Hospital
55 Fogg Road, South Weymouth, MA 02190
Phone: 781-624-8413
To page call: (781)-624-8123, pager # 7757
http://www.southshorehospital.org
From this report, the Dieticians have set parameters they use for the BMI, which helps them select which patients they need to complete an assessment on.
From this list the Dieticians document the BMI in the nutrition assessment.
So together with this documentation by the dietician and the physician documentation of obesity, malnutrition or any signs of questionable malnutrition, you can either query or capture the BMI for coding.
Tiffany Andras LPN CDI
Renee
Linda Renee Brown, RN, CCDS, CDIP, CCS
[Boy, does it hurt having to let the CCRN go after 24 yrs]
-Jane