Carol S. Gifford MSN, RN, CPHQ

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Redesign the Paradigm Efficient Clinical
Documentation in an Electronic World


Sue Ryan RN, CPAN, BSN Quality Improvement
Nurse Institute for Healthcare Quality
Innovation University Hospitals Case Medical
Center
Kristen Bates MBA, RHIA, CCS, CDIP Corporate
Manager Health Information Services University
Hospitals  

Carol S. Gifford MSN, RN, CPHQ Quality
Improvement Nurse Institute for Healthcare
Quality Innovation University Hospitals Case
Medical Center
Kelly Skorepa BSN, RN, CCDS Corporate Manager,
Clinical Documentation Improvement University
Hospitals  

Sara Hissong BS, RN Clinical Informatics Liaison,
EMR Change Management
Sally Streiber BS, MBA, CPC, CEMC Manager, Coding
Compliance and Education, Compliance and Ethics
Department University Hospitals   
Raymond Krncevic, Esq. Associate General Counsel


Erica E Remer, MD, FACEP, CCDS Physician Clinical
Documentation Education Coordinator University
Hospitals
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Objectives

• Identify bad documentation practices
• Judge and generate superior clinical
  documentation
• Assimilate electronic tips and tools to be more
  time efficient

University Hospitals
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Improving Documentation
November 22, 2014
University Hospitals
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Improving Quality

• Communication
• Of medical care provided
• Perception of outcomes

November 22, 2014
University Hospitals
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November 22, 2014
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Institutional Clinical Communication
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November 22, 2014
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Were going to cut and paste kids. Commas
matter.
November 22, 2014
University Hospitals
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Aoccdrnig to rscheearch at Cmabrigde Uinervtisy,
it deosn't mttaer in waht oredr the ltteers in a
wrod are, the olny iprmoatnt tihng is taht the
frist and lsat ltteer be at the rghit pclae. The
rset can be a toatl mses and you can sitll raed
it wouthit a porbelm. Tihs is bcuseae the huamn
mnid deos not raed ervey lteter by istlef, but
the wrod as a wlohe.
Quality Assurance/Peer Review Report Privileged
Pursuant to O.R.C. Section 2305.24, .251, .252
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November 22, 2014
University Hospitals
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ONE IS A MISTAKE MORE IS A MESS
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University Hospitals
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Fact or Fiction?

• I dont have time to document well

November 22, 2014
University Hospitals
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Do you have time NOT to?!

• Legal
• Timing is everything
• Internal inconsistencies
• Right hand doesnt know what the left hand is
  doing
• Rationale
• Lack of specificity

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University Hospitals
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Do you have time NOT to?!

• Denials
• Utilization Review
• Clinical Documentation Integrity Queries
• Audits

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University Hospitals
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Tell the Story!

• Substance is more important than length

November 22, 2014
University Hospitals
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(Non) Progress note
Service Cardiology   Subjective Data
is a 84 year old Female who is Hospital
Day 6. Pt seen and examined at bedside. She has
AD, poor historian. Pt appears comfortable. Overn
ight Events Patient had an uneventful night.
November 22, 2014
University Hospitals
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History?
Chief Complaint Patient comes in for a routine
checkup F/U on DM and HTN also c/o left sided
chest pain   History of Present Illness Pt. has
been notating his blood sugar for the past few
weeks. Pt. came to discuss it with doctor.
November 22, 2014
University Hospitals
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Daily Progress Note for
Visit , Final, Entered, Signed
in Full, General Subjective Data
is a 90 year old Female who
is Hospital Day 2. Objective Data
November 22, 2014
University Hospitals
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University Hospitals
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Quality Assurance/Peer Review Report Privileged
Pursuant to O.R.C. Section 2305.24, .251, .252
STOP THE BLOAT!
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November 22, 2014
University Hospitals
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November 22, 2014
University Hospitals
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History?
Chief Complaint Chest pain   History of Present
Illness 64 year old with history of previous MI
1999, c/o 1 week of intermittent achy 4/10 left
sided chest pain with diaphoresis when walking
his dog.
Duration, Timing, Quality, Severity, Location,
Associated signs and symptoms, Context
November 22, 2014
University Hospitals
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November 22, 2014
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yesterday morning. Patient to ask in the
breakfast, and 80, and feel well. After taking
at its. There are related off to know when he
was sitting at the at the dinner table and his
granddaughter was in his lab and he started
feeling a lot of nausea, belching, Margaret
abdominal pain, even to the bathroom 3 times
yesterday. He was not work today, via he denies,
fever, chills, sweating.
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November 22, 2014
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November 22, 2014
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5/28 Cardiomyopathy - EF 25-30 on
echocardiogram earlier in month - Re introduce
hydralazine will give 20 mg lasix IV once
today - Will optimize HF meds   5/29
Cardiomyopathy - EF 25-30 on echocardiogram
earlier in month - Re introduce hydralazine
will give 20 mg lasix IV once today - Will
optimize HF meds   5/30 Cardiomyopathy -
EF 25-30 on echocardiogram earlier in month -
Re introduce hydralazine will give 20 mg lasix
IV once today - Will optimize HF meds  
November 22, 2014
University Hospitals
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Documentation (CMS)
May use macros, but must provide customized
info that is sufficient to support a medical
necessity determination. ..must sufficiently
describe the specific services furnished to the
specific patient on the specific date. If both
the resident and the teaching physician use only
macros, this is considered insufficient
documentation.
November 22, 2014
University Hospitals
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Dont Propagate, Cogitate!
Mindful Editing
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Good documentation
What constitutes good documentation?
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Good documentation

• Accurate, consistent
• Relevant
• Complete, but concise
• Organized and easy to follow
• Timely

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ED note, HP, Consult Note

• Timely
• Original
• Logical narrative
• Appropriate detail
• Pertinent positives, negatives, and abnormals
• Support your conclusions

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Progress Notes

• Timely
• Dont copy and paste from day to day
• Dont leave everyone wondering why is the patient
  still here (because nothing seems to be happening
  or changing)
• Dont let the only change from day to day, BE the
  day

November 22, 2014
University Hospitals
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Office Notes

• Have at least 1 chief complaint / reason for
  visit (not follow-up, not no complaints)
• Address all chief complaints in HPI, ROS, and PE
• Mindful editing of CP or template from visit to
  visit
• Support action plan

November 22, 2014
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AND IMPROVED
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Subsequent Hospital Days/Established Patient

• (Hi)Story
• What has happened?
• How is the patient feeling?
• Have the symptoms changed?
• Any clinical events of note?
• Observations (PE and testing)
• Document your work-product
• Make templates
• Analysis and Plan (MDM)
• Status (original problem, new issues)
• Interpretation of tests, procedures
• Medical necessity for new orders
• Focus of treatment
• Documentation of definitive diagnoses

S
O
A
P
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Analysis Plan

• Most important part of the documentation
• Dont regurgitate the HPI or the interval history
• Synthesize, analyze
• Readable
• Consultants need to be clear on recommendations
• Evolving (progress notes). Dont CP the same
  assessment and plan every day.

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6x-7 3x-5 5x78 4 7 28
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Analysis Plan

• Evolve diagnoses
• Resolve diagnoses
• Recap major diagnoses in discharge summary

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Dont Attest, Invest!
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Attestation and Signature

• An unsigned note is an unbillable service
• Resident documentation without attestation is an
  unbillable service
• Unattested and/or unsigned notes cannot be
  utilized to support any other service
• The date of service can be adjusted if you are
  signing on a different day, presuming you SAW the
  patient on the earlier day

November 22, 2014
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Documentation Audit Tool
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Chief Complaint Explicit Statement
Historical Narrative Advances understanding of why patient is still in hospital
PE PE appropriate to condition, accurate, identifiably unique
Data Acquisition and Interpretation Appropriate testing, reviewed and analyzed
Assessment (Diagnoses) Clear analysis and synthesis all problems current with appropriate diagnoses
Plan All identifiable problems with reasonable, clear plans MDM commensurate with severity
Attending Input Attending generated or additional added-value documentation and signed within 24 hours
Succinctness No gratuitous CP, no import of irrelevant info
Accuracy Consistent w/ clinical picture, no incorrect info, mindfully edited, trustworthy
Comprehensibility Understandable, organized, advances the story of the patient
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Ebbinghaus Curve of Forgetting
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Efficiency in the EMR
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Efficiency in the EMR

• Technology
• Have the technology work for YOU
• Utilize your ancillary help (CC, PFSH, ROS)
• Patient questionnaires (be sure to review,
  validate, sign and date, scan into record)
• Dragon (Password)

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Dont remove another disciplines content from a
template
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Efficiency in the EMR

• Acronyms
• Acronym expansion in UHCare Word macros for AEMR
• You can incorporate other peoples acronym
  expansions

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Efficiency in the EMR
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University Hospitals
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Efficiency in the EMR

• Acronyms
• Acronym expansion in UHCare Word macros for AEMR
• You can incorporate other peoples acronym
  expansions
• Favorites
• Copying another clinicians favorites in Problem
  List Manager
• Can use CTRL Click, CTRL-Z and open document
  details of multiple documents at once

November 22, 2014
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Efficiency in the EMR

• Build filters
• Re-ordering orders
• Utilizing Favorites (prescriptions, types of
  documents you use frequently)
• To see old records, click All available charts
  and change the date range using Authored Date
• Learn the meaning of icons could add labels

November 22, 2014
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Efficiency in the EMR

• Radio buttons
• All other systems have been reviewed
• Normals, My normal
• Mindful editing

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UHCare Physician Support Line

• 216-286-6200
• Available 24/7

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Efficiency in the EMR
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Take-Away Points
What did you learn and do you think would be
valuable to pass on to others who werent
present?
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University Hospitals
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Thank You.