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Original Investigation |

Effect of a Documentation Improvement Program for an Academic Otolaryngology Practice

Suhael R. Momin, MD1; Robert R. Lorenz, MD1; Eric D. Lamarre, MD1
[+] Author Affiliations
1Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio
JAMA Otolaryngol Head Neck Surg. 2016;142(6):533-537. doi:10.1001/jamaoto.2016.0194.
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Importance  Physicians recognize the value of accurate documentation to facilitate patient care, communication, and the distribution of professional fees. However, the association between inpatient documentation, hospital billing, and quality metrics is less clear.

Objectives  To identify areas of deficiency in inpatient documentation and to instruct health care professionals on how to improve the quality and accuracy of clinical records.

Design, Setting, and Participants  A single-arm pre-post study was conducted from January 1, 2013, to December 31, 2014, among 17 attending and 12 resident physicians treating 1188 patients at an academic medical center. Data from 1 year prior to the intervention were compared with data for 10 months following the intervention. All increases were analyzed as a percentage increase after the intervention relative to before the intervention.

Interventions  Areas for improvement were identified, and all physicians in the department received education on inpatient coding and documentation.

Main Outcomes and Measures  The capture rate for complications or comorbidities and major complications or comorbidities, the case mix index (the average diagnosis related group relative weight for a hospital or department), and severity of illness and risk of mortality scores.

Results  A total of 1188 inpatients were included in the analysis: 743 in the preintervention period and 445 in the postintervention period. Review of our documentation identified major areas of comorbidity that were frequently underreported. Inadequate nutrition diagnoses (moderate malnutrition, severe protein-calorie malnutrition) were most often underreported. In addition, we found inadequate documentation supporting the presence of neck metastases. Among 1188 patients, the case mix index increased 5.3% (from 2.81 to 2.96) after the intervention, but this was not a statistically significant difference (P = .21). The normalized case mix index increased 21.7% (from 37.3 to 45.4; P < .01). The percentage of patients with a documented complication or comorbidity or major complication or comorbidity increased 27.1% (from 50.2% to 63.8%; P < .01). The percentage of patients assigned a severity of illness score of 3 or 4 increased 24.3% (from 34.7% to 43.0%; P < .01). The percentage of patients assigned a risk of mortality score of 3 or 4 increased 32.1% (from 18.7% to 24.7%; P = .01).

Conclusions and Relevance  After educational sessions, multiple measures of patient acuity increased significantly owing to improved documentation of common comorbid conditions. Although physicians intuitively appreciate the importance of good documentation, education on the technical aspects of coding can significantly improve the quality and accuracy of clinical records.

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Documentation Flash Card

Flash cards were developed to help residents document qualifying comorbidities accurately. Contact information for our department’s Clinical Documentation Improvement specialist is obscured for privacy reasons. Comorbidities were written in black if they affected the All-Patient Refined Diagnosis Related Group, blue if they qualified as a comorbid diagnosis or complication (CC), and red if they qualified as a major comorbid diagnosis or complication (MCC). A/P indicates assessment and plan; CAD, coronary artery disease; CHF, congestive heart failure; CVA, cerebrovascular accident; D/C, discharge; DX, diagnosis; Fib, fibrillation; HNI-DRG, Head and Neck Institute diagnosis related group; H&P, history and physical; MI, myocardial infarction; POA, present on admission; TIA, transient ischemic attack.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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