One of the findings in the original CAMP Method study was a significant disparity between genders. While we were not hypothesizing that gender differences existed in clinical documentation practices, the study none the less revealed at least one key difference.
Ruthann's CDI Blog
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Ruthann’s CDI Blog…..informal writings about clinical documentation in patient records…everything here is tested through my work and research on CDI….nothing here is “official”. I hope you will find it to be a useful, perhaps even supplemental tool for your work. And, on a really bad day, something to help uplift your spirits and gain some perspective! |
Thank You WsHIMA!
I had the pleasure yesterday of speaking to the members of the Washington State Health Information Management Association (WsHIMA) at their annual meeting in Seattle. What a perfect day....it was sunny in Seattle, the meeting was well attended (almost 300!) and the morning session was kicked off with video messages from Rita Bowen and Alan Dowling. There was some reference to renewing AHIMA values, vision and mission statements - which was a perfect entry for my discussion on CDI Training with the CAMP Method..... Physician shadowing at an academic medical center
Here is a case study for your consideratiion: An academic medical center on the East coast employed all physicians affiliated with the system and the hospital. An audit of the physicians’ office notes revealed inconsistencies between the documentation in the record and the level of the bill that was generated. Physicians were adamant that their patients were all very complicated and that, even though the documentation did not support a level 4 visit, they had in fact, performed a level 4 visit. The organization was concerned about the findings, but the bigger question was, “what can we do to ensure that the documentation is reliable – in other words, that the documentation reflects what actually occurred during the visit?” CDI Everywhere, Not Just Acute Care
Because the most significant amount of clinical documentation per patient occurs in the inpatient setting, many organizations confine their clinical documentation program focus to inpatient records. However, clinical documentation and its impact permeates every patient care setting. Most healthcare in the United States occurs in the outpatient setting. In 2008 there were over 900 million physician office visits, 95 million visits to hospital outpatient departments, and 114 million emergency department visits. Compare that with 35 million inpatient hospital discharges (excluding normal newborns). In general, there are approximately 1.1 billion outpatient visits in the U.S. compared to approximately 35 million inpatient visits to acute care hospitals annually.
Last Updated on Wednesday, 07 April 2010 22:44
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Breathe deeply and slowly...
Did you know that Yogis believe we can extend our lives by taking fewer, deeper breaths? After re-reading all of the intense blog postings from last week, I felt like I needed to take a few deep breaths! So for those of you who felt that same way (and those of you who didn't), I thought you might benefit from one of the posts on my Integrative Medicine site about the benefits of breathing deeply and slowly..... Smoking Cessation: One more look
Yes, I know I've talked about smoking cessation documentation on at least 2 other occasions. But here's the thing.....this measure is not just a CMS quality measure, it is also a key component in the Stage 1 UM for EHR implementation. There are two possible reasons for the inclusion of smoking cessation in Stage 1. It's either considered a key clinical documentation and counseling/treatment concern. Or, it's easy to collect, so CMS thought it should be added so hospitals would have at least one criteria they wouldn't have to complain about. My vote is for the former. If smoking cessation counseling is part of the QMs, it's not just easy, it's significant. So, what does this mean for CDI? HIT Committee: progress notes are where it's at
In a review of Stage 1 activities for MU of the EHR, you will not find a mention of progress notes. And, as any CDS'er worth their weight in salt knows, progress notes contain some of the most challenging and often some of the biggest goldmines for clinical documentation improvement. So, for progress notes to be omitted from Stage 1, feels confusing at best. Apparently, the HIT Committee felt the same. In their February 17th letter to Dr. David Blumenthal, they recommend that electronic progress notes be included in stage 1 MU for the EHR. What's all this about SNOMED?
The use of SNOMED is referred to in several areas of the pproposed final regulations for MU criteria for EHR implementation. While we're all familiar with ICD-9-CM (and, hopefully soon to be ICD-10), we may not know as much about SNOMED. So, I thought now would be a good time to take a look at SMOMED and how CMS views its role within the EHR. SNOMED is the acronym for Systematized Nomenclature of Medicine. SNOMED is a clinical healthcare terminology that was designed for use in EHRs, not paper-based health records. It contains over 311,000 codes (and growing!) compared to the 14,000 or so codes contained in ICD-9-CM and 68,000 in ICD-10. |
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