Clinical documentation improvement: impact and importance for your hospital.

How to improve clinical documentation

It is important to understand how gaps in documentation and the corresponding coded data impact the patient’s expected length of stay, the hospital’s mortality rate, and many other outcome measures, such as those on the Canadian national list of patient harm indicators.

Many of these indicators are publicly reported or benchmarked against peer organizations and it’s essential that this information is captured accurately and be a true reflection of the care provided by the hospital. 

Documentation in the health record has always been critical to the patient, the physician, and healthcare organizations. However, hospitals are paying more attention to the quality of the documentation and the resulting data that is coded, abstracted, and submitted to the Canadian Institute for Health Information (CIHI) and provincial ministries. Improving the quality of clinical documentation helps improve patient outcomes, and allows for better planning, delivery of services, quality metrics, and appropriate funding.

Converting medical documentation and clinical terminology into correct codes, from a long list of options, can be challenging. And it is even more difficult when the medical documentation is not clear, specific or accurate, often due to missing or incomplete information.

Inadequate documentation often results from missing information leading to higher readmission rates, longer length of stay (LOS), increase in harm indicators, costs and medication errors. Better documentation helps ensure there is no ambiguity with the diagnoses or treatment, and it facilitates improved communication between clinicians.

What is the purpose of Clinical Documentation Improvement?

Clinical Documentation Improvement (CDI) is a process to facilitate an accurate representation of healthcare provided through complete and precise reporting of diagnoses, comorbidities, and procedures to ensure the acuity and complexity of the patient is available to be coded. Many Canadian hospitals are implementing CDI programs, one such hospital is Niagara Health Systems.

Niagara Health Systems implemented a clinical documentation improvement (CDI) program, including an enhanced physician query process, to improve the accuracy and completeness of their medical records and found both health care and organizational benefits.

Having knowledge of specific deficiencies in documentation and coding within an organization is the first step in identifying the need and requirements for quality CDI. The next steps can then be initiated to ensure proper education, engagement, and process. Ultimately the goal is improved health care.

CDI Chart

The impact of clinical documentation improvement on hospital funding.

It is crucial that hospitals accurately reflect the level of patient acuity in the medical record so the facility can be funded appropriately for the level of care that was given. Physician documentation drives case mix groups (CMG) and clinical codes that determine funding allocation for the hospital. CDI ensures the data conveys the hospital’s true patient complexity. This in turn leads to appropriate hospital funding for the level of service that was provided.

What makes a successful CDI program?

Successful CDI programs appoint a CDI specialist to ensure the documentation fully reflects the patient’s episode of care. This process enhances patient outcomes and in turn enables complete and accurate coding and the allocation of an appropriate CMG assignment.

Allocating resources to CDI training and development is an investment that will produce future returns for health care organizations, including:

  • Concise and complete documentation that reflects the delivery of high-quality health care services - including a more accurate reflection of the acuity of the patient and resource consumption.
  • Support for the coding of health records to their greatest level of specificity and therefore, submission of high-quality data and information to CIHI and the provincial ministries. 
  • Facilitation of a more efficient way of collecting key data elements in order to ensure more accuracy in the reporting and analysis of hospital data and information.   
  • Greater ability to focus on accountability and quality around patient outcomes or mortality rates, and meet the measures outlined in accountability agreements, activity-based funding models and other quality-based initiatives. 
  • Optimization of potential funding and appropriate reflection of costs per weighted case.

Learn more about clinical documentation improvement.

Interested in learning more? Read this white paper on clinical documentation improvement.

 

About the Author

Kim Myrick

[enBio=Kim has a background in medicine, neurology ICU, community, and intensive care nursing from various hospitals in Canada. With a deep medical and community knowledge as well as project management experience, Kim joined 3M to integrate clinical nursing into the CDI platform. With over 20 years of medical experience, Kim is very passionate about improving clinical documentation to accurately reflect the quality of care that hospitals provide and to develop best standards for improving patient safety and outcomes. ],[enJob=Clinical Nursing Specialist, 3M Canada],[frBio=Mme Myrick a une formation en médecine, en soins intensifs en neurologie, en soins communautaires et en soins infirmiers intensifs provenant de divers hôpitaux au Canada. Possédant des connaissances approfondies en médecine et en soins communautaires, ainsi qu’une expérience en gestion de projet, Mme Myrick s’est jointe à 3M pour intégrer les soins infirmiers cliniques à la plateforme d’ADC. Comptant plus de 20 ans d’expérience dans le domaine médical, Mme Myrick est passionnée de l’amélioration de la documentation clinique afin de refléter plus précisément la qualité des soins prodigués par les hôpitaux et d’élaborer les meilleures normes qui soient pour améliorer la sécurité et les résultats des patients.],[frJob=Infirmière clinicienne spécialisée, 3M Canada ]

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