Post death query

fentona@bronsonhg.org

Our facility is focusing a lot this year on severity of illness / risk of mortality at time of death. Mortality rate E/O ratio. I have been tasked to run a daily "death report" and calculate SOI/ ROM on all deaths and if they are not a 4/4, to then review the records for any missed opportunities. This process was implemented 3 weeks ago. I am looking for input on records where I see no missed opportunities, but the patient is not a 4/4. Thoughts on using the following blanket statement as a reminder to the provider writing the death summary. "This patients severity of illness / risk of mortality at time of death is ?/? out of 4/4. Please assure all co morbidities and new diagnosis are documented in death/ discharge summary to accurately reflect this patients severity of illness/risk of mortality at time of death.
Would you consider this a leading query or inappropriate? I would appreciate any input.
Thanks,
Amy
Amy Fenton, R.N.
Clinical Documentation Specialist
Bronson Hospital
Quality and Safety
601 John Street
Box 59
Kalamazoo, MI 49007
Phone 269-341-8442
Fax 269-341-8330
E mail fentona@bronsonhg.org

annnd2009@gmail.com

Hi Amy,

I would wonder if you should tell them their current score—especially in writing. I think having a discussion and explaining that they seem well on paper would be okay but having that on a form may get scrutinized. I think- "assure all co-morbidities at time of death..” seems appropriate.

I don’t know if I would call it leading, it may get questioned as to ethics or coercion (made that up not sure anyone would actually say that). But since money should not be brought up I think the soi/rom actual scores might need to be watched closely too…

Just my opinions,

Ann

katysuegood@gmail.com

I have been reviewing all mortalities for Pdx/SOI/ROM for 4 years. Even if documentation is perfect you will not always get to a 4/4. Typically these patients are very elderly frail patients, those with endstage cancer, etc. As long as I believe the chart is maximized, I do not worry unless the SOI/ROM is very low (any 2's) or it’s a unexpected death like an ortho case with a SOI/ROM of 3/3 or less. In these rare cases I refer to an MD advisor to make sure I am not missing anything.

I am not sure whether or not the query is technically 'leading', But I don’t think its indicated. I think the ethics of it would be questionable as it does not meet any of the guidelines for when a query is indicated that I can think of.

Per "Managing an Effective Query Process", indicators for query placement are:

• Clinical indicators of a diagnosis but no documentation of the condition
• Clinical evidence for a higher degree of specificity or severity
• A cause-and-effect relationship between two conditions or organism
• An underlying cause when admitted with symptoms
• Only the treatment is documented (without a diagnosis documented)
• Present on admission (POA) indicator status


Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

fentona@bronsonhg.org

Great point Kathy, thank you. I am feeling kind of stuck. Management wants a "reminder" sent to each physician if their patient is not a 4/4 at time of death. They are who is requesting the physician be told the current SOI/ ROM. Any thoughts or ideas would be appreciated
Amy

ggoodman@virginiahospitalcenter.com

I would be hesitant to send such a letter also.
I would be afraid it may make the provider feel like he should be adding something to get a "better score."
I would be nervous they may feel inclined to introduce new diagnoses that weren’t actually a major concern during the admission.
However, if you did notice a certain diagnosis that you think was missed I think it is completely appropriate to Query for that specific diagnosis!
And as mentioned before you won't always have a 4/4 and that's expected.

Best,
Greta

angelisa.romanello

Hello Amy,
I am amazed that management is requiring this notification. As Katy stated, not all death records will move to a 4/4 however if the record is complete I believe this is more important.

Everyone once in a while you will see an unexpected death of an ortho patient or quite possibly an otherwise healthy patient. We have seen some of these this year with the extreme volume of flu cases we have received.

I believe the mission statement of CDI is to obtain a clear and accurate picture of the care and monitoring of this patient. If this is done the SOI/ROM should follow.
Good Luck
Lisa


Lisa Romanello, RN,BSN,FNS,CCDS
Manager, Clinical Documentation Improvement
Quality and Compliance
CJW Medical Center
Office phone: 804-228-6527
Cell phone: 804-629-0396
AHIMA Approved ICD-10 CM/PCS Trainer
Angelisa.Romanello@HCAHealthcare.com

katysuegood@gmail.com

Does management have a clear understanding of how SOI/ROM work? They may not understand that even patients that die will not always be a 4/4. And O:E ratio is calculated based on ALL patients so it is generally not an issue that some death charts will not be a 4/4.

If they insist contact be made with the physician, I would attempt to do that in person with the provider as opposed to placing a query for 'additional dx' on the record.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

fentona@bronsonhg.org

Lisa,
Thank you for your input. Managements goal is 90% of all mortalities be a 4/4. I feel frustrated in that I believe as you do that our mission is to obtain a clear and accurate picture. Some patient will never be a 4/4. I think it becomes difficult to explain that unless you are familiar with how the system works. I am feeling they just want this goal, but don’t necessarily understand the process.

Thanks Again,
Amy

martin.conroy

I think you have to be careful your query is not a "fishing expedition". I like all queries to be based on clinical information found in the record. Maybe you need a process through your physician liaison that cannot be construed as revenue enhancement through a leading query . We have done a death review for a number of years but questions are always based on something in the record.

Martin Conroy
Director CDI
Temple Health
267-235-4238

evanspx@sutterhealth.org

I don't think there is anything in the statement cited that is not appropriate...a specific question is not being posed, and the provider is being reminded to document any pertinent conditions. I also believe it is appropriate to discuss quality issues, such as ROM scoring, with providers given they are 'graded' on this coding system.




Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.412.9421

evanspx@sutterhealth.org

I agree that it is not practical to expect ALL expired cases to score 4/4. However, I don't see this statement as a QUERY - no specific question is being posed. I see this as another of many such documentation reminders used to remind a provider to thoroughly document all pertinent conditions. I certainly agree that if/when a specific query is introduced, Best Practice Guidelines should be considered.




Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.412.9421

katysuegood@gmail.com

I can see that argument Paul. If not a query and not included as a part of the permanent record it may be less problematic. When we were on paper I used to include a letter with retro queries on death charts explaining that the patient had a lower than optimal SOI/ROM and that this is why they were being queried (I think I modified a letter I found in the forms and tools library). This was not a part of the medical record, but faxed to the providers office as a cover letter with the query and other clinical information. I no longer do this because we are electronic.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

evanspx@sutterhealth.org

Point of Clarification: The writer did not state if this documentation reminder was considered a Permanent Part of the Legal Record. If so, I'd wordsmith it a bit and make it a bit more eloquent. However, I had thought this was general tip sheet provided to the clinician when the clinician completes Expired Cases. (But, not a 'query').

We educate our staff 'all the time' about ROM/SOI scoring via all manner of media, including letters, e-mail and PowerPoint presentations. We stress that ROM/SOI scoring directly affects all manner of risk-adjusted metrics used for a wide range of reporting purposes.


Providing the clinician with a letter and a score for each case as part of a documentation review does not seem inappropriate? If I were the Attending, I would personally want to know if I had an expired case with a score of "2" or less based on my documentation..they depend upon us to compute the scores and compliantly tell them 'why' a score may only be a '2' and also compliantly interact with them in order to positively impact a poor score in a compliant manner.

I just see this as part of the process of education and communication.

Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.412.9421

fentona@bronsonhg.org

I would like to add a little clarification. We work in epic, our CDS staff send queries in the coding information tab, so they are a permanent part of the medical record but not disclosed for review processes unless specifically asked for.
A lot of comments have mentioned physician liaisons. That would be wonderful, but we do not have one. This has been brought up on numerous occasions and shot down on numerous occasions.
Our main facility has 404 inpatient beds, our overall beds system wide is around 600.
The statement being discussed is communicated through the coding info tab like we would send a query in and the physician views it in their epic inbox.
I really appreciate all of the discussion. Tons of helpful information.
Amy