CDI in ED?
Curious,
What are your plans, goals, expected process/activities, etc. for placing a CDS in the ED?
Is anyone else doing the same?
We tried that at one point (doing reviews of pts admitted and waiting for a bed assignment), and found that the documentation was usually very inadequate to do an effective and fair review....usually had to completely repeat the review the next day on the floor. Queries are difficult to pose when there is not complete documentation, nor is it truly possible to know that one had any effect (what was already in the dictated H&P for example made the query unnecessary).
Don
What are your plans, goals, expected process/activities, etc. for placing a CDS in the ED?
Is anyone else doing the same?
We tried that at one point (doing reviews of pts admitted and waiting for a bed assignment), and found that the documentation was usually very inadequate to do an effective and fair review....usually had to completely repeat the review the next day on the floor. Queries are difficult to pose when there is not complete documentation, nor is it truly possible to know that one had any effect (what was already in the dictated H&P for example made the query unnecessary).
Don
Comments
As you say, your queries are probably irrelevant, unless your goal is to massage dollar impact numbers, because you can ask for diagnoses before the docs have even seen the patient...and that's unethical, IMO.
If the pt is sitting in the ER two days waiting for a bed, that's another story, but you can always wander down there and find them.
Renee
Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital
didn't get any responses. We plan to have someone verbally talk with
the docs when we see a missed diagnosis and have them write it
immediately. For example, when intubating, ED docs rarely write
respiratory failure. Same for acute blood loss anemia, or hemorrhagic
shock - as a trauma center, we see this a lot. Docs on the floor are
reluctant to answer queries for things that happened in the ED. I think
it will work out well. Especially with APR severity of illness.
Stacey Forgensi, RN, CCRN, CCDS
Clinical Documentation Specialist
Erie County Medical Center
sforgens@ecmc.edu
Pager 642-1011
We do review the ED and the ED transitional unit (EDTU). The query placed
in the ED "folder" doesn't always follow the patient up to the floor but
the response rate in the EDTU unit is wonderful. Our ED is VERY busy and
the diagnoses are not just symptoms and the status isn't always
observation - so clarification is well worth our while !
Gail Marini MM, RN, CCS
Manager Clinical Documentation (CDI)
Finance Department
781-624-8413 B-7757
We do not review ED cases. The documentation can be somewhat skeletal. In addition when the patient gets to the floor - the attending and residents may have a completely different take on the diagnoses for the patient.
We also have a significant number of patients admitted to our OBS unit from the ED. We do not review these cases since they are billed as outpt. You are right, the H&P completed when the patient arrives on the floor usually contains much more detail than the ED documentation.
It is not a good use of our resources.
Renee
Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital
The attending is ultimately responsible for the Final PDx. However, you do not totally dismiss anything that is documented in the ER visit. Once that patient is admitted everything that occurred from ER to discharge is taken into consideration.
The ER is usually where I look for Lasix given if I am trying to determine if Heart Failure is going to be my PDx. Was it treated? Yes - in the ER. Same for dehydration. Was it treated? Yes - in the ER. I also look for the mention of Decubitus Ulcers and the Stages and then I can call it to the attention of the attending.
I look at my VS, Cultures ordered to determine if Sepsis was POA, O2 SAT's - even those done in the ambulance - for Resp Failure. When a patient was intubated so I can get that >95h on a Vent $$.
I don't know about other ED Docs but ours are pretty right on with their Dx's. I can usually begin to put a very clear picture together.
Our CDI Physician Trainer spent quite a bit of time with our ER Docs when he was here and pointed out the importance of their documentation.
Are you referring to the "72 Hour Rule"?
Personally, I have always taken their documentation into consideration when coding.
AHA Coding Clinic
I noticed several postings on CDI in the ER and think most of the postings are missing the point of CDI in the ER. Efforts at CDI in the ER and CDI in general should be not be entirely focused on coding, DRGs and financial recimbursement. Instead, efforts in the ER on clinicl documentation improvement should be on affecting positive change in clinical documentation in support of medical necessity for admission to the hospital, accurate depiction of patient acuity reflective of the need for diagnsotic studies, accurate representatation of phsyician clinical judgment, amount of work performed and rationale for physician clinical impression and resulting plan of care.
This approach is a win-win for the hospital and the physician, capitalizing upon the opportunity to assist the ER physician in demonstrating a clear picture of medical necessity for his/her E & M assignment while at the same time helping the hospital demonstrate medical necessity for inpatient admission versus outpatient service.
Unfortunately our ED physicians provide minimal documentation - what is there is used by the coders. It gives me a starting point re: treatment, presenting symptoms, etc. We would not send a CDI to the ED - there are times when something like respiratory failure may?? be documented in the ED and not at time of admission - I would use the ED documentation as basis for a query - but that rarely happens.
We will be transitioning to an EMR over the next couple of years - that should help with all documentation.
I wonder how a dedicated ER CDS would work in practice. Is the CDS going to stand at the ER doc's elbow and tell him what to write? By the time there is meaningful documentation (i.e., reviewable) in the chart and the chart is available for review, the patient and the chart are out of the ER.
That is not to say that the CDS couldn't do a significant amount of education with the ER physicians, and then follow up later to let them know how they are doing. A good ER dictation is very helpful as a jumping off point, particularly when (as often happens in my hospital) the H/P is either missing or painfully bare bones. As far as using the CDS to push IP vs OP, I'd better be seeing the case managers in the ER driving that bus before I'm expected to take on that responsibility.
Renee
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
"Anyone who has never made a mistake has never tried anything new." -Albert Einstein
I agree with you Robert. We have a full time case manager in our ED and it is the case manager's role at our facility to ensure the that the patient meets criteria to be admitted and that the documentation supports that level of care.
There is not a real benefit for us reviewing charts in ER.
I know this is off topic, but our CDI team is curious to know how many CDIS work on holidays.
Paula Sonn
Baptist Hospital Beaumont
N. Brunson, RHIA
Clinical Documentation Specialist
Bay Medical Center
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
No holidays - no weekends
Donna
Shands at the University of Florida
It is interesting to me now (2 years later) that our higher-up's have decided that the ER visit is a separate encounter and will be treated as such - therefore unless carried over by physicians on the inpt case, ER diagnoses are not valid.
Charlene
That having been said, our facility has internally decided to query when the ED MD states a dx but the admitting/prog notes/D/C notes fail to mention what the ED MD documented. This prevents the risk of conflicting documentation, and further buttresses the documentation.
--Juan
That is correct. The caution comes in with people picking up
differentials or working diagnoses off the ED for coding. Then you may
get conflicting data with the attending dr.
You can use the ED report as documentation in the scenarios you described
below. ie present and treated/treating.
Stacy Vaughn, RHIT, CCS
No weekends or holidays!!
Thank you,
Susan Tiffany RN, CDS
Supervisor
Clinical Documentation Program
Robert Packer Hospital & Corning Hospital
570-882-6094 pager 465
Fax 570-882-6768
Tiffany_Susan@guthrie.org