It All Starts with Documentation

by Julie Dooling

In my April post “Quality Data Starts With Us” I discussed the importance of identifying patients correctly the first time. I think of this as Step #1 in capturing quality healthcare data for our patients.

Step #2 is in a race with Step #1, and which comes out ahead is just about too close to call. Step #2 is the process of creating a complete picture of the patient through reliable, precise, complete, consistent, clear, and timely clinical documentation.

The overall information lifecycle depends heavily on the data in Steps #1 and #2 being correct. If the clinical documentation does not strive to meet or exceed these data characteristics, the integrity of the data suffers from the beginning.

This step cannot be accomplished without the commitment and expertise of our physicians. As Wilbur Lo, MD, CDIP, CCA states:

“Our clinicians are a cornerstone in the information lifecycle because our clinicians are the main source for patient data. Based on documenting each patient’s chief complaint, along with the salient findings from the history and physical examination and the clinical significance of the diagnostic tests, our clinicians will synthesize this information and arrive at a diagnosis or multiple diagnoses. Then, our clinicians will design treatment protocols and initiate therapeutic procedures which are tailored to each patient. The integrity of patient data hinges on the proper documentation practices from our clinicians, who are the stewards and the storytellers for each patient’s encounter. Simply put, “if it was not documented, it never took place.”

Steps #1 and #2 set the stage for a successful clinical documentation improvement (CDI) program. Knowing that the data is trustworthy, the analysis and reporting of the data is elevated in a positive direction.

Measuring the data can be complicated since there may be many different options. The following are a sampling of various reports and metrics to consider when measuring the performance of your CDI program:

  • Dashboard considerations that address both strategic and operational metrics (from Hess). Note: This is not a comprehensive list from the publication:
    • Concurrent Queries
      • Number of queries placed
      • Response Rate (Target=90%)
    • Concurrent Reviews
      • Number of patients eligible for CDI review
      • Percentage of patient reviews with one or more queries.
    • Retrospective Queries by HIM
      • Number of queries placed
      • Response Rate
    • Process Flow
      • # of CDI reviews accessed in CDI system by HIM
    • Documentation Compliance
      • Charts missing documentation at time of coding
    • Quarterly Change in Severity Levels
      • Levels 1-4

Note: Additional reporting and metric options can be found in AHIMA’s Clinical Documentation Improvement Toolkit within AHIMA’s HIM Body of Knowledge and a new title from AHIMA Press, Clinical Documentation Improvement: Principles and Practice.

Julie A. Dooling, RHIA, CHDA is a Director with the American Health Information Management Association (AHIMA). With many years of healthcare experience, Dooling has served in various roles including transcription service owner, HIM manager for a large integrated delivery network, and senior sales support for leading document management vendors in the US and Canada. Dooling serves as an instructor for the Certified Health Data Analyst exam preparation workshops and has authored many articles, briefs and toolkits related to data in today’s healthcare.

Original source:
Dooling, Julie A. "It All Starts with Documentation" (Journal of AHIMA website), June 17, 2015.