How to Measure Optimal Physician Documentation

dbutlerdbutler
edited May 2016 in CDI Talk Archive
This may seem to be a contrary question.....as in a sense CDI is directly aimed at this, but.....

Having some discussion with an executive VP about severity profiling, expected mortality, etc. and the conversation started to explore how can the organization measure individual physician's documentation (how close to optimal is the documentation to allow full capture of SOI & ROM?). We certainly noted that there already are a couple of stand in measures --
**First could be CDI & coding (who conduct post-discharge queries) query rates. The draw back for query rate is that we are not as thorough in querying for the severity documentation as we are in the potential financial queries (though we do both). Also, we don't have an objective data source to benchmark other than our internal specialty group query rates.
**Second is the mortality index or expected mortality rates. Both of these would be compared to peers from within their specialty and the mortality index/expected can be compared to the data by service line for other organizations with in the UHC database.

These ideas are unfortunately more of a substituted measure, so looking for ideas / suggestions / thoughts that would provide a direct measure.

Thanks!
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



Comments

  • heidi.koenigheidi.koenig
    edited May 2016
    Our CDI program just passed its one year mark. The first 3 months of the program we were able to lower our ROM rate by 2%. I personally took more pride in that then our CMI going up by .07, which made the CFO positively giddy. I do keep the $$$ in mind, but do not query on that specifically.

    Thanks,

    Heidi Koenig, RN
    Clinical Document Specialist
    Ocala Regional Medical Center
    Heidi.koenig@hcahealthcare.com
    352-401-1686
  • catladyrncatladyrn
    The concern I would have is do you give more credit to the physicians who are already documenting well and require less prompting, or to the physicians whom you drag kicking and screaming into compliance (aka answering your queries). In a perfect program, the physicians would be so well educated that there would never be need for queries...which paradoxically would mean you are doing your job incredibly well, but you would show up via your statistics as being a complete slacker!

    Makes my head spin...not that that takes much.

    Renee


    Linda Renee Brown, RN, CCRN, CCDS
    Certified Clinical Documentation Specialist
    Banner Good Samaritan Medical Center
  • robert.hodges2robert.hodges2
    edited May 2016
    Something I do, but I can do because all of my providers are employed and the facility is relatively small with a lot of outpatient care, is review a sample of all providers notes each year and provide them with a report with "opportunities" to do better. I normally do ten charts for ten different providers each month. I look for documentation specificity, legibility issues, potential missed diagnoses (an abnormal test result in their chart that is not addressed in the note), copy and paste issues (the joys of the EMR), and abbreviation use. Overall metrics for these reviews are reported to the Medical Record Review Committee.

    So far it is well received and occurs between me and the provider only with no report going to supervisors. I use it for education and even had a provider call me to request a re-review to see if they had improved. It takes me a year to get through all of our providers at this rate, but it is manageable and does give them individual feedback.


    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
     
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens

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