Department of Quality Documentation Documenting as great as the care you give Has anyone ever heard of QD? CDI? Queries? #3400.159 Rev. 10/16
Quality Documentation s Role Reviews charts to find missing, specify, or conflicting diagnosis to make sure there is a clear, accurate and complete picture during the hospital stay. Concurrently review the entire in-patient chart, usually by day 3-4 of hospital admission Seek to clarify any documentation that is unspecified, unclear, conflicting or missing Send Queries to providers to obtain any additional clarifying documentation QD & Coding is a resource team that works in collaboration Queries can be sent after discharge prior to bill. 2
Your documentation tells a patient s story. H&P = Introduction Progress/Op Notes = Body Discharge summary = Conclusion It is critical to paint a clear picture from start to finish and cover the initial situation, changes through the stay, and a clear summary that brings it all together.
Your documentation makes a difference GenMed: captain of the ship- H &P- PN - DC Summary Pulmonary/ICU: COPD-respiratory failure- Asthma- shock- sepsisbronch Cardiology: CHF- Afib- Aflutter- STEMI/NSTEMI- valvular disorders- echo Neuro: GCS- hemiplegia- CVA specifcity Anesthesia: blood products or unstable vitals pre/intra/post op ER: differential diagnosis- abnormal lab work- presenting symptoms ID: sepsis- localization of infection- cultures NES: cerebral edema- compression of brain- GCS- CT/MRI Radiology: diagnosis exam and IR procedure Surgery: blood loss- pain- obesity- thrombocytopenia-op note Pain management: opioid dependence
Documentation Tips Document the diagnosis(es) rather than signs and symptoms SOB due to respiratory failure Be specific! acute, chronic, acute on chronic, or exacerbation. acute on chronic systolic heart failure Link diseases /diagnoses to their underlying causes Pancytopenia due to chemo Indicate suspected, possible, or likely when treating a condition empirically, such as a gram negative pneumonia. These diagnoses need to be reconfirmed at the time of discharge to capture the medical decision making and resource consumption
Documentation Tips continued Use your consults! Dietician notes- malnutrition Wound care- pressure ulcers Clarify diagnoses that are present on admission (POA) Pressure ulcers, DVT, fracture Avoid use of arrows/symbols (e.g. low sodium, low plt, abnormal hgb) Hypernatremia, thromboctyopenia, anemia Clarify the significance of laboratory, radiology and other procedures by summarizing these results in your documentation. Diagnoses can not be coded from these reports per CMS rules and guidelines. * prefer to not copy and paste*
How does your documentation make a difference? First and foremost, accurate documentation helps provide better care for the patient Support medical necessity Reflect treatments rendered to your patients and how sick your patient is and how likely to die Validate the length of stay Support CMI (case mix index) compensation Decrease denials Accurately reflect quality indicators and publicly published outcome measures Accurately reflects the conditions treated, monitored and resources utilized throughout that patients stay. Represents the care you provided to your patient Provider Quality score 7
Severity of Illness (SOI) & Risk of Mortality (ROM) Quality measures that affect population health, risk of mortality and morbidity are becoming a vital part of the health record. Diagnoses such as Malnutrition and Obesity are sought out to help define appropriate medical care in compliance with CMS guidelines.. 95% of queries are quality impacting, only 5% financial
Hospital Acquired Conditions (HAC) and Patient Safety Indicators ( PSI) Foreign object retained after surgery Air embolism Blood incompatibility Pressure ulcers Falls Manifestations of poor glycemic control Catheter-associated urinary tract infection Vascular catheter-associated infection DVT/ pulmonary embolism after lower extremity an operation Surgical site infection Post operative DVT/PE, Respiratory Failure & Sepsis If you are not able to determine present on admission status- unable to determine choice does not code to a HAC
Principal Diagnosis Secondary Diagnoses COPD Observer A Observer B Observer C COPD Exacerbation w/o CC/MCC COPD Exacerbation w/cc Chronic Diastolic/Systolic CHF Oral Lasix -chronic home medication Medicare DRG 192 191 190 MS-DRG AMLOS 3.3 4.0 4.9 COPD Exacerbation Relative Weights 0.7313 0.9321 1.1578 Severity of Illness Risk of Mortality Level 1/minor Level 1/minor Level 2/moderate Level 2/moderate w/mcc Acute Diastolic/Systolic CHF IV Lasix Level 2/moderate Level 2/moderate Reimbursement $5,143.20 $6,322.03 $7,647.09
Pneumonia Specificity Pneumonia can be specified based on the treatment. Negative or inconclusive sputum cultures do not preclude a diagnosis of a specific bacterial pneumonia in patients with the clinical evidence of this condition. (per: AHA Coding Clinic). If you are treating a suspected, possible or probable gram negative or other resistant pneumonia please document as such. CAP and HCAP are not specified 11
Pneumonia Principal Diagnosis Secondary Diagnoses Observer A Observer B Observer C Observer D Simple Pneumonia, unspecified Simple Pneumonia, unspecified Simple Pneumonia, unspecified Complex Pneumonia: Treating Gram Negative w/o CC/MCC w/cc AKI w/mcc ARF w/mcc ARF Medicare DRG 195 194 193 177 MS-DRG AMLOS 3.3 4.4 5.8 8.2 Relative Weights Severity of Illness Risk of Mortality 0.7111.9695 1.4261 2.0549 Level 1/minor Level 1/minor Level 2/mod Level 1/minor Level 3/major Level 3/major Level 3/major Level 3/major Reimbursement $5,024.61 $6,541.63 $9,222.24 $12,023.79
The Query Process A Query is an electronic question posed to a provider by a QD RN. Most queries are derived from a template bank and are always in a multiple choice format All queries are meant to be non-leading and the best judgment of the practitioner is advised Once answered, the query becomes a permanent part of the medical record 13
Answering The Query If a query is sent it will populate in the Epic in-basket for chart completion A query that is sent on a template can be answered in just a few clicks Select a response from the drop down menu of options or manually fill in the appropriate response as needed A signed query becomes a progress note 14
What if I Don t Answer? QD personnel are required to follow-up on any query sent after 24 hours and every 24 hours thereafter. This can be done through email, text, page, office messages or personally After 72 hours an escalation process is initiated to facilitate compliance QD personnel are located on each campus M-F to provide assistance or answer questions 16
Visit us on the Intralee! -Health Information Management -Physician Documentation Resources
Physician Documentation Resources Includes past education on a variety of topics.
The following physicians serve as liaisons for the Quality Documentation Department: William Carracino MD, Vice President & Chief Medical Information Officer Michael Bolooki MD, Medical Director of Informatics If you would like to reach out to Dr. Bolooki for a peer to peer discussion, please email him at michael.bolooki@leehealth.org #3400.159 Rev. 10/16
Thank you Any Questions? 20