Review Worksheets (Paper)

dbutler

For those that don't have a completely integrated electronic system....
If using a purely paper based worksheet, or a worksheet printed from software,

do you place worksheets on the medical record/chart with every update?
do you leave the worksheet and write updates on the existing?
do you NOT leave a worksheet on the record and then make sure it is joined with the record in HIMS prior to coding?

What kind of process has been successful and how has the process changed over time?

We are talking about stopping placing worksheets that don't have queries on the record and develop a process to ensure the worksheet is easily available to coding when the case is being coded.

I am looking of ideas and experiences of what works and why........knowing there are a lot of variables.

Short of an integrated electronic software system.....has anyone ideas to get worksheets into an electronic format that is easy to share (in addition to scanning at discharge)?

Thanks,
Don

Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com

dog

All worksheets and queries are placed into the chart, so every time I make a change or add information, I have to shred the copy in the chart and put a new worksheet in. At discharge, the queries are scanned in with the rest of the chart. The worksheets are held back for several days or until the chart is coded. My supervisor does not want my worksheet to influence the coders in their decision-making. After they code, then I reconcile my DRG with theirs.

I don't really know why I need to put the worksheets into the chart, other than I've been told to do so. If the chart is requested by an outside auditor, my worksheets do not go with it. If our consultant comes to review charts, I just print a copy from my software, and of course if I need a copy, I can do the same.

Renee

Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital

Unknown

My worksheets do not go in the chart. They are just for my personal
reference. I make a lot of notes on my worksheets of things to follow
that are just my notes. I keep them until the chart is coded. Our
queries are not a part of the permanent record either. The only time
the queries stay in the chart is if the MD documents on the query and no
other place in the chart.

jyeton.mccoy-johnigan

I was wondering, if your worksheet is not part of the permenant record, how are your coders able to take the answered Query, if it is not documented anywhere else in the chart? If you get audited, won't they wonder where the documented info is?

We keep our worksheet in the chart. It stays in the chart until final coding. Our coders will then attach our worksheet to their final code sheet and we will pick both sheets up at the end of the day.

We will write on our papers in the chart when we re-review the case. I usually attach my new sheet,if I make changes, to the one already in the chart, so the coder who reviews it, will see what I saw in the beginning. (wow, long sentence!) May be an extra step, but it has really helped a few times to "fight my case" later.

Unknown

Progress notes.

--Juan

digardsk

We use worksheets printed from software. We reprint when there is a DRG change or a change to a query (clarification). Or, if a long LOS, we reprint occasionally. We do NOT reprint with every note we make! Occasionally I will make a hand written note, but usually only if the patient is discharging and I have a little change.

They are not part of the permanent record, and are returned to us from coding with their final coding. The coders practice is to never look at our sheet until they have coded.

One small reason for leaving them on the open chart - quite a few other people use them for a resource!

Kim

dallend@einstein.edu

Currently we do not place our worksheets on charts. We did in the past - it was too confusing to the physicians so we stopped. Our worksheets stay with us - when we reconcile our cases we attach the attestation to our worksheet and keep them at our desks for 3 months.
We enter our review dates and queries in Soft Med. We do not document DRGs so it is not necessary for the coders to see our worksheets. They can view query information in Soft Med.

stacy.vaughn

Where do you document this in Softmed? Did you purchase a quality program
or added it on as another field somewhere in Clintrac?

stacy.vaughn

If you do not monitor the DRG's, how do you track success in the program?

paula.sonn

We leave a working Drg sheet on the chart so our case managers, soc. Workers and coders can all utilize it as needed.

Paula Sonn, RN CDIS

dbutler

Could you provide examples of other uses?

Thanks, Don

jyeton.mccoy-johnigan

Thanks Juan for your response, but my question was acutually to Laura's email. I was confused as to how their facility was able to take it off their Q sheet if it wasnt written anywhere else in the chart.

At our facility, we cannot take anything off our sheets but education. If a physician documents his resonse to our Q and it will impact the DRG, and that is the only place it is written, we will do a second letter and ask it to be written in the progress notes.

paula.sonn

The soc. Workers and case managers use it for LOS. It's not always accurate, but it gives them an idea of LOS and it helps them with their
DC planning and they use it when communicating with Docs re: their LOS on pt.s

nbrunson84

The only information we place on the chart are our Queries. Those are
removed by the Scanning/prepping group and given to the Coders who then
return them to CDS's

Our coders to not have access to our CDI information - I don't think it
would be that useful to them.

N. Brunson, RHIA
Clinical Documentation Specialist
Bay Medical Center

Unknown

My queries instruct the doctors to chart their answer in the progress
notes or discharge summary. If they answer on the query and not in the
progress notes, then the query will stay as part of the permanent
record. When they answer the query in the progress notes, then I will
pull the query off the chart as the dx is in the progress notes for
coding. Our coders don't see my worksheets. I reconcile things after
they have coded the chart and discuss with them if there is a
discrepancy. (very easy to do as I'm in the same office as the IP
coders) If a query isn't answered while the patient is in house, I
leave the query on the chart for the coders to see. Then once they code
the chart, they can determine if the MD needs to be queried
post-discharge. Our coders queries are a part of the permanent record.

dbutler

One of the (admittedly infrequent -- but still with value) benefits for us of having the worksheet available to the coders -- after they've coded the chart, they will use the worksheet as a spot check reference, especially for secondary diagnosis (several times a month allows them to capture something they missed that affects the DRG).

We also benefit greatly from the feedback from the coders.

Part of reason for my original question is the amount of time placing updated worksheets on the chart involves -- often toward the end of the day when all updates are recorded in the software -- can be an extra 30+ minutes of what might be essentially un-productive time each day.

We do have mechanisms to retain worksheets and queries though these are not treated as part of the legal medical record -- all queries need to be addressed in PN or DCS to capture the documentation.

The worksheet that is on the paper chart is scanned into softmed / chartview which is what the coders reference.

Don

dallend@einstein.edu

Our IS dept customized a screen we did not use in SoftMed.

dallend@einstein.edu

We are judged based on the increase in SOI/ROM, CMI. We also check are charts after discharge to evaluate query impact on DRG - most do not impact DRG but they do impact SOI/ROM.

stacy.vaughn

Is this SOI/ROM based on per chart or an overall trending to a higher
level? You track your SOI/ROM before your query/doc improvement and then
the final or what it would be post query?

digardsk

The CMs use it as a guide for expected LOS, and appreciate our clinical summary - it can be a time saver for them. I know that the dieticians are looking at them, don't know about other disciplines.

Kim

nbrunson84

We strongly encourage all information to be documented within the
medical record. Our goal is to have a properly documented record at
discharge. When the Coders code the chart the documentation is already
there for them to code because we queried for it on the floor and it was
documented in the progress notes. Our Queries are there to "guide" them
in knowing what we were looking for.

Example: If I query for Acute Renal Failure the physician documents it
within the chart. I check the chart daily for that information. When
he writes it - I code it and it is there when the coder codes the chart.


If for some reason I do not get back to the chart (weekends) and the
patient discharges they know to look for the documentation of Ac Renal
Failure within the progress notes - and then they code the Dx.

Now, if for some reason he never answered on the floor and the patient
discharges - and they still need the MCC/CC they will continue the Query
after discharge. THIS query will become a permanent part of the medical
record.


Our software has a reconciliation report generated daily. Once that
chart is final coded, if my DRG and the Coder's Final DRG do not match
it will kick out onto this report. I review why the DRG's did not
match. If I see a problem with the coding or POA's I refer it to the
Lead Coder to review. She reviews - if she agrees with me she gets with
the Coder and changes are made. If she doesn't agree she refers to the
Coding Supervisor. If the Coding Supervisor doesn't agree with me I let
her word be the final answer. And I document it in my notes.


N. Brunson, RHIA
Clinical Documentation Specialist
Bay Medical Center

dog

Golly, I love this group! Inspired by this thread, I just asked my supervisor if I could stop leaving the worksheets on the charts, only the queries, and she agreed. Yippee!

I don't understand about how the coders wouldn't be able to find the answer to the queries. The physicians are asked to document their response in the progress notes and/or discharge summary. If there is no change in documentation, it means they didn't agree with what the query was asking. It's my job to make sure all my outstanding queries are answered one way or the other. If a patient is discharged with an outstanding query, I will email my supervisor and the coders and tell them to hold the chart until I get my answer.

The case managers get the working DRGs from the report that corporate generates in the morning, based on data I input as I do my reviews. And they know they can always ask me how confident I am in a given DRG.

Renee

Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital

dallend@einstein.edu

For queries - we check impact pre and post.
Our director receives reports from Finance on a monthly basis with our CMI, admissions, CC/MCC capture rate. She also pulls reports re: SOI/ROM.
Our program has been in place almost 8 yrs now and we have had a significant increase in our SOI/ROM especially for our expired patients. We have also seen a significant increase in our CMI.

dallend@einstein.edu

That is great!

ctrygar

I utilize a worksheet that I keep with me in a folder and carry it with me when i go to the floors. We do not have a computerized charting system. I get a print out every morning of all patients diagnosis and insurance information. On my worksheet i have a place for MCC and CC's. As i audit the chart if i come across a cc i place the diagnosis in the cc colum with data to support it along with the date it was documented same goes for MCC's. If i have a query on the chart i put a red star next to what i am querying when it is answered i write the diagnosis under cc/ mcc along with the date answered. When the patient is discharge i place my worksheet in a folder dated the day of discharge along with other odds and ends such as discharge summaries or labs that need to be placed in the chart. The coders go threw this folder and pull out my worksheet and other info if present on the charts they pulled to code that day.. They reference my worksheet to see if queries obtained by my red star or other cc or mcc that i may have seen that they didnt see. At the end of the day i review the worksheets they coded and left in a pile for me . This seems to work for me. I know on occasion when they didnt have my worksheet, maybe i was off work or it was missed at times they have missed a cc in the chart not neccassarily one that i queried for so it is a good checks and balance system. I am the only one doing this job and i started this entire job with a backround only in nursing nothing in coding so it has been a work in progress.

cheri

dog

Cheri,

I think most of us RNs didn't come from a coding background, either, but I could be wrong. We weren't hired for our coding knowledge. I've certainly learned a lot about coding along the way, but I have nowhere near the coding skills our coders do.

It sounds like not only do you not have computerized charting (we don't, either), but you have no computer at all. You might want to ask your administration to set you up with a laptop computer that you can take with you on your travels. I would think a handwritten system would get very cumbersome and difficult to work with after a while. Not to mention a good encoder program is worth its weight in gold.

Renee



Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital

deanna.schad

We leave our worksheets on the chart regardless of MD query or not. Other disciplines use it as a reference. I believe it serves as a great tool to remind the physicians of the diagnoses they have documented earlier in the chart and many times ensures a continued flow of these diagnoses through the remainder of the chart.


Dee Schad, RN, BSN, CCDS
Clark Memorial Hospital
Jeffersonville, IN 47130