Average Number of Chart Reviews
I could use your help!!! Would you please share with me the average number of chart reviews and queries you generate in a typical day. I seem to be a "little slower" doing chart reviews than my coworkers, even though I have been in the department the longest. We are expected to do at least 35-36 chart reviews a day and on some days I average around 29-32 charts. I have been told that I document too much information in the database, "information I feel is pertinent to the review" and spend too much time in the chart. Other Doc Specs document just the bare minimun,do not spend near as much time as me and have a "glowing number" of monthly chart reviews. I am writting this to get another Doc Spec's perspective on how they start their daily routines; set their priorities for chart reviews and following tasks. Any advice, cheat sheets or "shortcuts" will be greatly appreciated.
Regina McCroskey, BSN
MRMC Ocala,Fl.
Regina McCroskey, BSN
MRMC Ocala,Fl.
Comments
Email me privately and i'll call you
so many variables it's hard to say but on average I review 25-30 charts
a day. Some days I do more or less depending on if there are a lot a
re-reviews or new charts. The queries also vary; some days I don't have
any and others I have 6.
I also only document pertinent information and I do it in more of bullet
style. I don't spend a lot of time typing a story....it's too much for
the coders to read and they may miss the important points.
There are 3 CDIs in our office and we all work at a different pace. I
think the important thing is quality not quantity of your chart review.
Are you making significant changes when you query...are their queries
appropriate and are they missing query opportunities? It's not just
about querying either...is there any teaching that goes on while
reviewing?
I hope this helps.
Gina Spatafore, RN
Clinical Documentation Integrity Specialist
Beyond the daily reviews our department tries to be creative with Physician education, creating posters, handouts, etc. My point is there has to be more than just your head in a chart to really make a difference.
Judi Bates RN, BSN, CCDS
CDI Specialist
856-757-3161
Beeper 66x2906
I do not like wordy queries when I am able to get the point across with bullets or short ones.
The physicians overlook wordiness. They want the "nuts and bolts" of the query.
Colleen Stukenberg MSN, RN, CMSRN, CCDS
815-599-6820
There are only two of us so our productivity is get your priorities done first - queries and admission reviews (which may generate more queries) and when you are done goto your continued stays. On low census days I do continued stay/follow up reviews.
I shoot for 10 admission reviews per day and 10-15 cont. stays a day with an average of 5 queries. But all of those are variables. Sometimes I may get more admssion reviews/contiinue stay reviews done if I have less queries.
I am also wordy. (As you can probably tell!) I include all abnormal clinical indicators which may lead to a query and where I found them (H&P, Consult, LAB). I also include my PDx, MCC, and CC's in my reviews. I may include abnormal CXR results . For my CM's I include the ALOS for that DRG because our software does not include that info. I note if patient is scheduled for surgery or if its something I need to check for the next day.
If that patient moves to someone elses floor you can easily see all the activity I have generated.
I have had CDS's who only document the bare minimum and it ticks me off to no end when their patients move to my floor and I have to practically reinvent the wheel!
And when I train CDS's I tell them to document the way you want a patient to come to your floor. Do you want this patient - the one where you just easily pick up from where they left off or do you want this one that you will have to review from the very beginning because you have no idea what has been done?
Because I have coding and UM background I am constantly looking for medical necessity and I code my patients pretty indepth.
I type fast!!
I guess the most important question is quantity or quality?
As I said before, I would probably want to follow your patients than someone elses.
NBrunson, RHIA, CCDS
# of reviews depend on # of admissions. We review Medicare and one Medicare managed care plan. We have had months where we only had 400 reviews/person - that was due to low inpt #'s.
We have EMR.
Renee
Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center
How many hours do you work in a day? I just wonder how effective it can
be to look at so many charts? After a while I can't even see straight.
Gina Spatafore, RN
Clinical Documentation Integrity Specialist
I like to think I've mastered the art of cutting to the chase. I don't try to query until the physician has had a chance to, y'know, actually write something, and I don't try to beat a dead horse, because in the end, it's the physician, not me, who has to stand behind that documentation. If a chart is very complex and may have multiple opportunities for improvement, I quickly note them all, and then come back later and refine them--looking up coding clinics, trying re-sequencing, Googling more clinical information, etc. I might spend an hour on a single chart, but not until I've finished everyone else. I use templates on the computer to formulate my queries, which saves time, but I individualize them and pay attention to every single word that comes off my fingertips, because once the query goes out, I can't reel it back in. I work hard to ignore the pressures to find an cc/mcc and just focus on what is sloppy or vague about the chart. A lot of what I do I've learned by being a member of this forum.
Renee
It sounds like you do what I do. I'm just glad I don't have your volumes! Sounds like you are doing a great job for the patient and the facility. Don't let them wear you out!
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
populates from our Cerner ADT feed that was setup for another 3M product
into our DocMS or CDIS (when we get that). A time saver!
___________________________________________
Mark Dominesey, RN/BSN, MBA
Clinical Documentation Improvement Specialist
Health Information Management Services
Martha Jefferson Hospital
459 Locust Ave
Charlottesville, VA 22902
Judy Fisher RN BS
Clinical Doucmentation Improvement
Longmont United Hospital
Longmont Co. 80516
If these features (and others) are as good as they might be, that will give a real boost to ROI.
Wondering if anyone with experience with their CDIS / CEDIS module could comment?
Don
Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com
Never give in. Never, never, never, never--in nothing, great or small, large or petty--never give in, except to convictions of honor and good sense. Never yield to force. Never yield to the apparently overwhelming might of the enemy
Sir Winston Churchhill
issues with connectivity, I think it works well. We generate a work list
every morning and the program can filter that demographic information so
the only patients imported are the payers we review. During this
learning curve, we are doing Medicare only. The plan is to gain the
efficiency that comes with experience using the program, and then expand
payers.
We also have cross-trained our Revenue Integrity Specialists (RAC
responsible) to do CDI using CDIS, and that has worked out well based on
the internal educational helps in the CDIS software. The encoder is not
new to us as we had access to a stand-alone encoder (3M) to use for case
studies to educate MDs about SOI/ROM. So learning to use the encoder
hasn't really slowed us down.
The queries are pre-built and open as word documents that can be edited
as needed. That was important for us as we've identified criteria for
several diagnoses, taken them to Medical Staff Quality Mgmt. committee
and had the criteria approved by the medical staff. We built Word
templates outside of CDIS that we use for our queries since 3M said they
needed to charge for that formatting service. We've included the
criteria and the source reference that we developed and have approved.
We went to a lot of trouble to educate our MDs on ours and didn't want
to simply abandon content developed in partnership with our physicians.
It's a simple matter of cutting and pasting the verbiage into CDIS so we
can track types of queries within CDIS and get the report out of the
software. For those who haven't developed criteria, 3M has some in the
queries they provide, and that would likely be acceptable.
The reports that can be generated are the same ones we've used from the
beginning and can easily be manipulated internally for executive
reporting. I'm working on using the data available publicly to build my
comparative database, so contracting isn't necessary for us. However,
we've had a contract in the past for consultant-produced reports and
have already proven ourselves to management after 8 years of CDIP with
the same two nurses. I especially like the options of clicking on the
CDI button to have a list of the most common secondary diagnoses seen
with the diagnosis you've listed as principal. You also can go straight
to the ICD-(-CM text or to coding clinics regarding the diagnosis you've
entered, which saves a lot of time hunting for the info you need.
I think 3M may have hit a home run with this product. I just hope over
time the support/customer service is better than my past experiences. I
will give them a B so far.
Charlene
Julie Skagen RN BSN
CLinical Documentation Specialist
Medical Records
Bozeman Deaconess Hospital
1-406-522-1802
jskagen@bdh-boz.com
Linda, RN-CCDS
Maryville, TN.