clarifications
I would like to throw an idea out there and see if any one has tried it, and if so, how it is working:
I would like to stop placing worksheets on all the charts and only place the clarifications on the charts as needed.The intent to increase productivity and reduce any possible compliance risk, and also to minimize confusion with the providers.
I would like to stop placing worksheets on all the charts and only place the clarifications on the charts as needed.The intent to increase productivity and reduce any possible compliance risk, and also to minimize confusion with the providers.
Comments
*We've received comments from others (such as CM & nursing) that our worksheets are helpful to them in providing a brief clinical summary, as well as the benefits of estimated ALOS which shows on the worksheets.
*The visibility of worksheets helps with awareness of the program, and serves as a reminder to providers that this particular case does NOT have a need for documentation clarification (that they are doing a good job with documentation).
*Depending on your process, the availability of the worksheets for coding staff when they are final coding the case may help to prompt them to go back and look again at a diagnosis they might have missed or to give a second thought to PDX selection.
I am not sure what the concerns are for compliance risk -- CDI should be conducted in such a way that there is NO increased compliance risk -- let the light of day show on your work, you ought not have anything to be worried about. If not, perhaps reexamine the program.
For what it's worth....
Don
The few times a physician actually read my worksheet, it caused no end of confusion, because they thought I was the coder and they disagreed with the codes I had chosen. Otherwise they never looked at them. As it was, I had to change my query form to shocking pink and put a tab on it to get them to read the queries, much less the worksheets. I had the worksheets in the charts for over a year and people still thought I was the case manager.
Not having to put the worksheets in the chart meant not always having to fight to get to the charts, not struggling to get a printer to work from my wireless, and not having to pull out and replace my old worksheet every time I updated it. The coders already were not getting my worksheets because my supervisor thought they might be cribbing (they weren't). It was up to me to reconcile daily and let them know about discrepancies that I thought were in their court.
Just my perspective.
Renee
Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center
Kathy Shumpert, RN, BSN
Clinical Documentation Improvement Specialist
Howard Regional Health System
Office 765-864-8754
Pager 765-604-0424
Fax 765-453-8152
Proofread carefully to see if you any words out. ~Author Unknown
We stopped placing our worksheets on our chart about 4 years ago. We only place queries on charts now. It has decreased the confusion with our physicians.
We had a great deal of confusion with our physicians. They would write over our documentation - remove and add diagnosis and procedures. We would get "interesting" comments on our worksheets. They would be removed by unit clerks and other staff. Life has gotten much easier.
UM liked having our worksheets on the chart but they can always ask us a question if they need to. They pick a DRG based on their review and they are given a LOS based on their UM system.
We stopped assigning DRGs about 4 years ago - most of our discrepancies were related to add'l info after our last review - we now focus on accurate chart documentation. The DRG will be the DRG if the documentation is there to support it.
When we reconcile our worksheets we look at princ. dx and cc, mcc's.