I used to be a international medical graduate who along with some medical observe, had begun a profession first in managed care as a utilization administration coordinator after which as a medical researcher after ending medical faculty after which pursuing a public well being diploma.

Just a few years in the past, life took some sudden turns, and I discovered myself in a quite new area of well being care referred to as medical documentation enchancment (CDI). I didn’t perceive why a doctor’s word or what they documented was not at all times sufficient. I imply, they noticed and handled the affected person, isn’t their medical judgment and competency adequate?

Properly because it seems, a clever man or girl as soon as acknowledged: “If it was not documented, it was not achieved.”

Right here is an instance of what which means. You have got a affected person who is available in hypoxic, wheezing, doable pneumonia, he’s desaturating and requires oxygen, or in some instances, even BiPAP or — worse but — air flow. You point out in your notes that he has “respiratory misery.”

That is the place a medical documentation enchancment specialist like myself (You could be both an RN or have a medical diploma for this position in any respectable CDI program), will assessment the charts and ask a doctor if this actually is simply misery or is it doable the affected person will be going right into a extra critical situation, akin to acute or acute on persistent respiratory failure? Once more, the purpose is to not problem a doctor’s medical acumen or judgment however as an alternative make them suppose outdoors the medical field and attempt to have them be a bit extra particular with what they are surely diagnosing and treating.

As a doctor, chances are you’ll ask, “Properly why do I have to waste my time documenting when I’ve to see so many extra sufferers and the affected person was given the right care whether or not it was misery or failure?” The reply to that query, one which many a CDI, myself included, have been requested is, fairly merely, the severity of sickness and, probably, the chance of mortality. What if this affected person sadly expires? Had been all their comorbidities documented? This additionally results in the opposite piece of the puzzle, which is the massive unhealthy wolf of well being care — reimbursement and denials. If the affected person’s medical situation isn’t precisely documented in all charts, a supplier dangers medical necessity denials and decrease reimbursements and decrease high quality scores. It’s your documentation that results in the right DRG assignments and finally permits the coders to precisely code the charts earlier than they’re despatched off to billing and the insurers.

Right here is one other favourite gem of mine on this fantastic world of medical charts: I as soon as reviewed a affected person’s chart after I first began my new-found profession in medical documentation enchancment. The historical past and bodily acknowledged that the affected person was a 60-something feminine who had are available in for a sure chief criticism and was evaluated. Her gynecological historical past clearly acknowledged she was menopausal. So, think about the horror on my face after I learn a subsequent progress word by the identical doctor stating the lady is eight-weeks pregnant. I do a double take, return to the H&P and re-read that she is menopausal, after which on this word, it says she is eight weeks pregnant. I make my new trainee learn the word simply to ensure I’m not incorrectly studying this chart, and he too has that very same look of horror and confusion. We’re each medical medical doctors making an attempt to make sense of what now we have simply learn and brainstorm collectively to determine a believable clarification.

Is that this a medical miracle or a medical error in documentation?

We each agree to debate this chart on the subsequent case convention with our supervisor, and he or she too is surprised. Ultimately, we contacted the doctor who wrote the 2 notes, and because it seems, this was not a medical miracle, however a documentation error and a critical one at that. The doctor admitted that in his haste to finish charts, he had two completely different affected person charts open on the identical time and had in all probability lower and pasted from the unsuitable chart into the progress word. He was suggested to promptly right the error in his notes earlier than this chart was coded and billed. I’ll save the doable authorized implications, doctor documentation errors as a result of EHRs and the strain to see too many sufferers in too quick a time all for an additional dialogue.

So, the following time you obtain that pesky “question” from the CDI division in your facility, keep in mind: documentation, documentation, documentation!

Rabia Jalal is a doctor.

Picture credit score: Shutterstock.com

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