Module 1 Clinical Documentation Improvement (CDI)

• CDI stands for Clinical Documentation Improvement.
• By Dr. Mohamed Azmi

Content Overview

• Will provide an introduction to CDI
• Classification and Diagnosis Related Groups (DRGs) will be covered
• Standards related to CDI and coding
• Policy and procedure related to CDI
• The importance of medical records and review
• Rules and regulations in Documentation
• Data integrity and Key Performance Indicators (KPIs)

Learning Objectives for CDI

• Understand concept for CDI
• Understand proper documentation
• Know proper implementation in KSA
• Master auditing of medical records

Definitions

• Revenue cycle management (RCM) in healthcare enables organizations to get paid for providing services.
• The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), classifies diseases, injuries, and related health problems.
• The Australian Classification of Health Interventions (ACHI) classifies surgeries, therapies, and health interventions.
• Australian Refined Diagnosis Related Group (AR DRG) is a system that relates number/type of patients treated in admitted acute episodes of care to the resources required in treatment.
• The National Platform Healthcare and Insurance Exchange Service (NPHIES) is a centralized healthcare and insurance platform creating a connection between the insurance sector and Saudi's medical sector.
• Physicians spend 2 hours on electronic health records (EHR) and desk work for every hour spent with patients.
• Researchers observed just under 60 physicians from 16 practices during office hours.
• Observed that 49% of physicians' office hours were spent on EHR and desk work while just 27% was spent directly with patients, which includes the 37% of time spent on EHR and desk work when meeting patients
• Physicians worked an average of 1.5 hours per day after hours dedicated to EHR tasks.
• Physicians had more direct interaction time with patients with documentation support like dictation.
• Golden rule for medical documentation is, if it is not documented, it did not happen and cannot be billed.

Dimensions of clinical documentation improvement

• Medical coding
• Quality documentation
• Legal consideration
• Patient safety
• Technological impact
• Inpatient benefits

Enhancing Patient Safety

• Improving access to information, completeness of records, and timeliness of updates enhance patient safety.
• Treatment adjustments and monitoring patient progress also play a beneficial part.
• The safety comes from training and education, compliance with guidelines, standardization, and good documentation practices.
• Error prevention strategies and reducing errors is also important.

The Multifaced Role of the Medical Record

• Includes legal protection.
• It ensures compliance with healthcare laws and safeguards patient privacy.

Components of a strong medical record

• Progress notes are ongoing updates from healthcare providers with observations.
• Diagnostic tests with the results and medical findings.
• Treatment plans are the outline for all proposed medical treatments and therapies.
• Medical history of past health issues and treatments.
• Finally patient demographics, like name, identity, and contact details.

Characteristics of Satisfactory Documentation

• Clarity
• Conciseness
• Timeliness
• Accuracy

Authorized Members to write in health records

• Physicians
• Dentists
• Nurses
• Radiologists
• Lab technicians
• Patient Educators
• Other medical and paramedical staff with direct patients.

Complete health record

• Contains identity information of patients
• Includes any complaints/reasons for visit
• Contains history
• Has proper physical examinations
• Includes interventions from all workers, like nurses and physicians
• List of problems
• Proper family plans and history
• Health education

3. Documentation Rules

3.6 Clinic Notes:

• The notes should be documented immediately.
• All clinic notes should contain the following:
  • Current illness
  • Review of body systems
  • Pain
  • Family history
  • Social history
  • Physical examination details
  • Treatment plan and the diagnosis

Effective Medical Documentation

• Clarity, efficiency and adherence to guidelines are ways to obtain effective medical documentation
• By approving and not approving certain abbreviations in documentation accuracy and reliability can be ensured.

Approved and Non-Approved Abbreviations

• Abbreviations need to be used uniformly among physicians because they are often not unified.
• Abbreviations must be reviewed and using an approved abbreviation list to prevent error
• All medical team members must learn the list of standards
• The list must be updated with any annual adds or deletions.

Examples of Approved and Non-Approved Abbreviations:

• abn = abnormal
• ACC = accommodation
• ACE = angiotensin converting enzyme
• ACG = angle-closure glaucoma
• adv = advanced
• AIDS = acquired immunodeficiency syndrome
• AMA = against medical advice
• Ambl = amblyopia
• amp. = ampule
• ANA = antinuclear antibody
• ant = anterior
• AODM = adult-onset diabetes mellitus
• approx = approximately
• ARMD = age-related macular degeneration
• BS = blood sugar
• BUN = blood urea nitrogen
• BVA = best visual acuity
• CA = carcinoma
• CABG = coronary artery bypass graft
• CACG = chronic angle closure glaucoma
• CAD = coronary artery disease
• CAI = carbonic anhydrase inhibitor
• BVA = best visual acuity
• Cap.(s) = capsule(s)
• cat = cataract
• CAT = computed axial tomography
• CBC = complete blood count
• CHD = coronary heart disease

Key Documentation Rules

• The treating physician is responsible for health records
• The CDI must consistently maintain a standard
• Information like patient allergies should be provided

Documentation Rules Continued

• Physicians need to document all detailed information about patients
• All nurses must ensure the proper completion of nurse assessments
• All entries must be legible and clear

3.5 Symbols:

• All symbols and abbreviations must be medical approved
• List of permitted is important
• The pharmacy and CDI need to monitor all usage

3.7 The Medical Assessment:

• Must contain medical assessment, but not limited to:
  • Diagnosis (Presenting diagnosis)
  • Descriptions and symptoms
  • Medical history of the issue
  • Current medications
  • Any drug allergies
  • Procedure plans
  • Exam details
  • Proposed treatments

Helpful rules to follow

• Upholding confidentiality, data security, and protecting patient privacy, ensuring accuracy, providing correct information and doing timely updates
• Following policies, complying with standards, being compliant are all helpful rules to follow

Introduction to Diagnostic Perspectives

• Diagnostic perspectives improve quality clinical documentation
• Better documentation of patient health
• Plans to improve the service
• Improved outcomes

Importance and Purpose of CDI

• Helps create accurate medical health records, better care, and improvement of affected services, enhancing and ensuring accuracy in healthcare.

To ensure all medical records;

• Have solid and consistent documentation and facilitate integration between teams
• Better continuity of care, helps by supplying data

Medical Coding overview

• Diagnosis - Translates patient conditions into codes
• Procedures - Coding medical interventions and actions
• Services - Encoding healthcare services to patients
• Medical coding system works as a billing process for the healthcare teams.

Important Medical Terms

• ACHI, Australian Classification of health Interventions
• ICD 10, International Classification of Disease Australian Modification
• AR DRG Australian Refined Diagnosis Related Group, the coding is done automatically in the electronic health record.
• Specialty specific guidelines exist in the ICD-10-AM official coding guidelines.
• An official medical diagnosis coding should be made based on the ICD-10-AM

ICD-10-AM Documentation Requirements

• Identify the procedures and complications
• Documentation of all treatments
• To perform proper billing based on accurate coding in the system

Cycle for proper documentation includes

• Observations
• Assessments
• Diagnostic terms
• Coding Diseases
• And conditions
• Will all help deliver value (a solid result)

Coding Terminology

• Clinical staff use a clinical language.
• Coding team members use a separate coding language.

The Role of the CDI Specialist

• Bridging the potential "CDI Gap", the difference between the clinical and coding languages.

The Goal and Roles of a CDI

• Reviewing coding and ensuring coding adheres to set protocols
• Notes can often be incomplete and hard to interpret

Goals of the Medical CDI Specialist in the Medical field

• Identification of anything missing, conflicting, or nonspecific physician in documentation related to diagnosis and procedures
• Aiding accurate diagnosis and procedural coding, DRG assignment, severity of illness, and expected risk of mortality leading to appropriate reimbursement.
• To help improve on the communication between physicians and other team members

Role of Provider

• Providers need to accurately provide all patient health history, all present illness, and all courses of treatment.
• Precise documentation of decision-making for treatments and labs should be present.
• Diagnoses and treatments must be explained.

CDI Specialist training

• Nurses, Physicians and professionals must be well educated for AHIMA and ACDIS certifications.
• CDI Specialists analyze and interpret clinical documentation and data for clinical, laboratory, and radiologic indicators.

Transforming Healthcare Process

• Transforming healthcare documentation with technology improves:
  • data clarity
  • efficiency through automation
  • and easy access to information, so that those healthcare providers.
  • Quick data access to avoid errors through data entry and validation.

Good Documentation in Inpatient/Outpatient setting

Benefits of good documentation:

• High-quality documentation
• Improved patient care.
• Enhanced Communication.
• Improved Regulatory Compliance
• Accurate Billing and Reimbursement

Better Healthcare Outcomes

• Documentation accuracy leads to better communication
• Patient care quality ensures data capture and a high standard of care
• Treatment effectiveness is improved.

Improving CDI/Outpatient:

• Actively involve all healthcare providers in the documentation process to promote accuracy and completeness.
• To develop a constructive way to have healthcare providers receive documentation feedback
• Perform consistent reviews and compliance reviews

To have a skilled set of documents in medical records;

• Healthcare providers implement continuous education and training