five tips for optimizing clinical documentation improvement in emergency medicine

Five Tips for Optimizing ClinicalDocumentationImprovementin Emergency Medicine

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#1 Documentation Deficiency Failure to document medical necessity

for procedures.

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#1 CDI Optimization Tip

• Why did the patient present for care?

• What did the provider do for the patient?

• Why did the provider do what he/she did?

Example:When a NS bolus is ordered and administered, or CT of the head is ordered but any symptoms or complaints that would support the need for this study must be documented.

Make sure documentation of an encounter tells a story.

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#2 Documentation Deficiency Failure to document procedures

or its key components.

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Un- or under-documented procedures result in:

• Lost revenue

• Inability to charge for I&D

• Physicians losing costly procedures to the facility

#2 CDI Optimization TipMake sure that procedure information and the key components are accurately documented.

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#3 Documentation Deficiency Failure to document co-morbidities

influencing patient care.

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#3 CDI Optimization TipMake sure that physicians explicitly state the patient’s condition(s).

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#4 Documentation Deficiency Failure to properly document details

on diagnosis.

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Acuity Ex: acuity regarding bronchitis

Location Ex: location regarding sinusitis

#4 CDI Optimization TipEnsure that documentation includes these four key elements:

Cause Sometimes this is not known in emergency medicine.

Manifestation Ex: regarding diabetes

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#5 Documentation Deficiency Failure to support a diagnosis

with documentation in the exam.

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#5 CDI Optimization Tip

Consider this:When the physician observes everything is normal in the exam, yet the clinical impression states otherwise, there is a major issue.

Document all pertinent findings in the multi-system exam.