Defining Clinical Documentation

Have you ever heard of performance punishment? It is the phenomena wherein a person (or department) is penalized with extra duties for excelling. It is easy for clinical documentation integrity (CDI) staff to become overwhelmed by requests from other departments or hospital leadership when the mission and scope of CDI is undefined or poorly defined.

What is clinical documentation? In the broadest terms, it is content within the health record. It can’t be limited to narrative notes, which is also known as unstructured data, because many electronic health records (EMRs) attempt to simplify provider documentation through prompts that allow a response to be chosen through a dropdown menu. In some EMRs, the content within a provider note may not even be provider-generated; it may be data automatically pulled into the note due to EMR settings.

Some automation is easy to identify, like problem lists, but others may be less obvious, such as radiologist reports. Other clinical content may be provider-generated, but it may not have been generated today, if the provider uses copying and pasting to pull forward sections of a prior note. The point is, clinical documentation is a very big, unruly topic, so the scope of CDI practice needs to be defined within this cornucopia of data.

The American Health Information Management Association (AHIMA) often references the Generally Accepted Principles of Recordkeeping. Because the origin of CDI is health information management (HIM), it is worthwhile for CDI professionals to be aware of these standards – in particular, the principles of accountability, integrity, and compliance.

Accountability includes the concept of accuracy and completeness, both of which relate to the work of CDI professionals. However, these are broad concepts that need refinement within the scope of CDI practice. Is accuracy ensuring that all documentation is consistent within the health record, or that documentation that impacts billing is consistent and complete?

These are two different concepts, because the health record is both a clinical tool that supports patient care and a billing tool. There are also many who contribute to the health record, but code assignment is primarily based on the documentation of independent licensed professionals, whose documentation in the health record should be reviewed by CDI staff.

The original focus of CDI limited the concept of accurate and complete documentation to diagnoses and procedures that impact MS-DRG assignment, as most early CDI adopters only focused on Medicare beneficiaries. Should CDI expand this definition to include documentation that impacts quality reporting?

Quality is another huge topic, so if it does, perhaps it should only be quality measures that are based upon claims data?

This leads me to the principle of integrity. This concept also references the accuracy and completeness of the health record, but in the context of tracking changes to the record to maintain the integrity of information. The query process is most impacted by this principle.

Although CDI professionals may not have complete control over whether the query is part of the health record or how the query is documented within the health record, they do impact the timing of queries. I’ve had many conversations with CDI professionals who worry about querying a provider too soon. The reality is that the earlier documentation is clarified in the health record, the better it is for the purposes of creating a cohesive and complete record. Yes, the provider needs time to review new information, but if the provider has entered a note since new diagnostic information was available and did not address the concerns, a query is appropriate. The earlier a query is addressed, and documentation updated, the better.

Ideally, all queries should be resolved prior to discharge (unless the discharge summary is what leads to the query opportunity) to avoid amendments or addendums to the health record, and to expedite the coding process. A strong query process with a focus on quick resolution leads to better patient care and a healthier revenue cycle. CDI, physician, and hospital leadership should be focusing on more than just query rates, response rates, and agreement rates.

As I’ve mentioned in other articles, we need to be tracking query accuracy. Was a query needed? If so, was a query issued? Too often, CDI professionals allow other factors to influence if and when they query a provider. Leadership is usually data-driven, so they need to see the data, including the lack of response by difficult providers. But we also need to measure if there is a change in documentation behavior.

How often is the provider queried for the same topic? If the same provider continues to need querying for the same diagnosis, maybe it is time to take a different approach, like referring a physician advisor (if one is available) to the CDI staff. It is also important to track the query response rate in relationship to how long it takes to get a response.

A query response rate of 95 percent reached over a 30-day period is not very impressive. It also could lead to long bill hold times or rebills.

Lastly is the principle of compliance. Yes, as healthcare professionals, we are all aware of the Health Insurance Portability and Accountability Act (HIPAA) requiring patient privacy, but compliance also includes complying with all relevant laws, regulations, and standards related to health records. This is another area where things can be muddled with a poorly defined scope of CDI activities.

Are CDI the “documentation police?” What documentation is within their purview, and part of the review process? What about copying and pasting? Does CDI have a role in identifying use of it? Are there other resources within HIM that can support compliance activities if there are initiatives like problem list accuracy?

Supporting accurate documentation is a vague and likely impossible mission. Combat mission creep and burnout that can result from performance punishment by clearly defining the clinical documentation as it relates to the CDI review process.

Programming note:

Listen live this morning for the CDI Report with Cheryl Ericson on Talk Ten Tuesday 10 Eastern.