Intro to Clinical Documentation, Dr. Shirshekan, 3-15-2021 3

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University of Missouri, Columbia *

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7566

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Jan 9, 2024

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INTRO TO CLINICAL DOCUMENTATION ‣ Jonathan shirshekan, md ‣ Medicine-Pediatrics Hospitalist ‣ Physician advisor, utilization review
TEXT TODAY’S AGENDA ▸ Introduction to the multiple roles of physician documentation ▸ Understand the requirements of the admission & progress notes ▸ Learn some tricks and tips to improve efficiency ▸ Learn how to obtain relevant auto texts
TEXT WHY IS THIS IMPORTANT TO YOU NOW? ▸ Understanding why saves time and improves efficiency ▸ Average Time of Progress Note: 22 Minutes ▸ Residents of Tomorrow ▸ Attendings of Tomorrow ▸ Demonstrate Your Medical Knowledge
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TEXT START OUT STRONG ▸ Be Observant: Be critical of one another’s documentation style. Find what works. ▸ Be Smart: Avoid over-documentation. More is not better. ▸ Be Flexible: Attendings--right or wrong—may ask for you to adapt. ▸ Be Savy: Explore PowerChart and use its features to your advantage
EVOLVING ROLE OF THE PHYSICIAN’S NOTE
TEXT THE DYING ROLE OF THE NOTE ▸ Original Intent: Serve as Reminder for a Single Doctor ▸ With the EMR, notes are no longer used as the source for orders.
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TEXT THE ADDED FUNCTIONS OF THE PHYSICIAN’S NOTE ▸ Document care provided and rationale ▸ Communication between teams ▸ Medicolegal ▸ Reimbursement ▸ Consumer access ▸ Quality
GENERAL PRINCIPLES OF DOCUMENTATION
TEXT FOUR BASIC PURPOSES OF DOCUMENTATION ▸ Demonstrates service meets medical necessity ▸ Clinically communicate to provide excellent medical care ▸ Support billing ▸ Demonstrate quality of medical care (quality metric, medicolegal)
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TEXT QUALITIES OF GOOD DOCUMENTATION ▸ Accurate ▸ Relevant ▸ Complete, but CONCISE ▸ Organized ▸ Intelligible ▸ Timely
THE PATIENT’S POTASSIUM IS 7.3 Is this hyperkalemia? DIAGNOSES AND SPECIFICITY
TEXT CAPTURING DIAGNOSES ▸ Acuity ▸ Acute, chronic, subacute, etc ▸ Severity ▸ Mild, moderate, severe ▸ Specificity ▸ Left vs Right, Proximal vs Distal, Closed, etc ▸ Linkage ▸ Establishes cause and effect, examples: ▸ Opioid-induced constipation ▸ Aspiration pneumonia ▸ Sepsis due to E. coli
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TEXT DIAGNOSIS LIFE CYCLE (INPATIENT) ▸ Notes should get shorter over hospital course ▸ Record : Record initial findings ▸ Bright red blood per rectum ▸ Revise: Revise as more information becomes available ▸ Acute blood loss anemia secondary to colonic mass ▸ Resolve : As problems are treated “resolve” and remove them from plan ▸ Revisit: Revisit problems in discharge summary
ADMISSIO N NOTE
TEXT WHAT’S REQUIRED ▸ Comprehensive HPI ▸ Past History, Family History, Social History ▸ Comprehensive ROS ▸ Results of Labs/Diagnostic Studies ▸ Detailed Physical Exam ▸ Assessment and Plan
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TEXT WHAT’S REQUIRED ▸ Comprehensive HPI ▸ Past History, Family History, Social History ▸ Comprehensive ROS ▸ Results of Labs/Diagnostic Studies ▸ Detailed Physical Exam ▸ Assessment and Plan KEEP LIKE WITH LIKE!
TEXT AVOID THE PHRASE “HISTORY OF” ▸ Clinicians: The patient has a PMH which includes X which is still present. ▸ Coders: Something which is no longer present. It is resolved. ▸ “History of pulmonary embolism” ▸ I27.82: Chronic pulmonary embolism vs. ▸ Z86.711: Personal hx of pulmonary embolism
TEXT HISTORY OF PRESENTING ILLNESS ▸ Requirement: Comprehensive history requires 4 or more elements ▸ location, quality, severity, timing, associated symptoms, et al ▸ Tell the patient’s story, using their words as possible ▸ Like with like: This is the patient’s story. Do not mix vitals, lab findings, physical exam findings, etc into the story. ▸ Never copy and paste ▸ If present, clearly separate the ED/Outside Hospital Course
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TEXT REVIEW OF SYSTEMS ▸ Required ▸ Use an Autotext: ▸ A complete 14 point review of systems performed and negative except as noted in the HPI.
TEXT HISTORIES: ▸ Past History ▸ Social History: Tobacco, Alcohol, & Drug Use; Occupation ▸ Family History: Be specific. ▸ Not acceptable: Negative, none, non-contributory
TEXT PROBLEM LIST Use the Problem List to enter acute and chronic problems.
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TEXT USE THE HISTORIES TAB TO CAPTURE HISTORICAL DATA
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TEXT ASSESSMENT AND PLAN ▸ Arguably, the most important component ▸ Goal is to assess the relevant clinical data and provide a plan of management ▸ Like with Like: Keep data where it belongs ▸ Consider the use of a problem representation statement.
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TEXT PROBLEM REPRESENTATION STATEMENT ▸ One sentence summary that highlights the defining features of the case. ▸ Answers the following questions: ▸ Who?: Pertinent demographics & risk factors ▸ When?: Temporal pattern of illness ▸ What?: Clinical syndrome, key signs & symptoms. Source: Journal of General Internal Medicine, Problem Representation Overview
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TEXT PROBLEM REPRESENTATION STATEMENT [Patient name] is a [age, sex] with [up to three relevant medical problems] who presented with [concise summary of presentation] and was found to have [clinical syndrome, major signs and symptoms] . Who. When. What.
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TEXT PROBLEM REPRESENTATION STATEMENT Mr. Smith is a 71-year-old with hypertension, diabetes, and obesity who presented with acute, left-sided, exertional chest pain and was found to have elevated troponins with ST-segment elevation concerning for myocardial infarction . Who. When. What.
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TEXT CAPTURE RELEVANT ADMISSION DIAGNOSES ▸ Acuity ▸ Severity ▸ Specificity ▸ Linkage ▸ Establishes cause and effect, examples: ▸ Opioid-induced constipation ▸ Aspiration pneumonia ▸ Sepsis due to E. coli
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TEXT CAPTURE RELEVANT DIAGNOSES RELATED TO MORTALITY ▸ Respiratory Failure ▸ Encephalopathy ▸ Electrolyte Abnormalities ▸ Renal Failure ▸ Obesity/Malnutrition ▸ Coagulopathy ▸ Heart Failure ▸ Sepsis
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CREATE A PLAN ▸ Be a lumper: Lump related diagnoses ▸ Assess: Assess the clinical data and write your reasoning. ▸ Formulate the plan: Describe the clinical treatment/work-up. Include continuation (or not) of outpatient medications and why.
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EXAMPLE: ▸ Acute chest pain: ▸ Troponins 0.12 ▸ EKG with ST segment changes ▸ Start nitroglycerin and heparin. ▸ STEMI ▸ Given ongoing chest pain, elevated troponins, and ST- segment changes on EKG, patient has acute myocardial infarction. ▸ Plan to start ACS protocol including heparin drip, nitroglycerin PRN pain
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PROGRESS NOTE
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TEXT WHAT’S REQUIRED ▸ Chief Complaint ▸ Subjective ▸ Detailed Physical Exam ▸ Results of Current Labs/Diagnostic Studies ▸ Assessment and Plan
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TEXT CHIEF COMPLAINT/SUBJECTIVE ▸ Chief Complaint: Why the patient remains in the hospital ▸ Subjective: ▸ Consider this a follow-up of the chief complaint ▸ Consider a hospital ROS ▸ Do not write “no acute events overnight" or “patient seen and examined at bedside.
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TEXT ROS ▸ A ROS is not required for a progress note.
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TEXT PHYSICAL EXAM ▸ Document a detailed physical exam. ▸ Do not copy and paste the physical exam. This is fraud and at high risk for being flagged for audit.
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TEXT ASSESSMENT AND PLAN ▸ Patient Assessment: ▸ The custom at MU is to write a patient summary which describes the patient’s presentation, the hospital course, major complications, and disposition. Its intended use is to provide a hand- off between providers and is often copied into the discharge summary.
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TEXT IS THIS HELPFUL? 34 YEAR OLD FEMALE WITH A PAST MEDICAL HISTORY OF CEREBRAL PALSY, NEUROGENIC BLADDER S/P BLADDER RESECTION/ILEAL CONDUIT PLACED (12/2018), HX OF DVT/PE S/P IVC FILTER (2009; XARELTO),ASTHMA, MDD, RECURRENT UTI THAT COMES TO THE ED FOR A 1-2 DAY HISTORY OF HEMATURIA (IN OSTOMY BAG WITH SMALL CLOTS), BILATERAL FLANK PAIN L>R, SUBJECTIVE FEVER, NIGHT SWEATS. UROLOGY CONSULTED IN THE ED WHO RECOMMENDED CT UROGRAPHY. CT UROGRAPHY LEFT PYELONEPHRITIS, STENTS IN PLACE. MEROPENEM STARTED (6/14–P). ID RECS ARE TO SWITCH TO CEFEPIME CONTINUE FOR TOTAL OF 7 DAYS ANTICIPATED STOP DATE 6/20 AND CONSIDER SPEAKING WITH UROLOGY AGAIN REGARDING EPISODIC HEMATURIA AND RENAL STONE. UROLOGY REQUESTING PATIENT BE BROUGHT DOWN TO THE CLINIC TODAY 6/17 TO EVALUATE STENTS, OKAY TO START ANTICOAGULATION. 6/17: B/L URETAL STENTS REMOVED, CONSIDER ANTIBIOTIC SUPPRESSION ONCE DISCHARGED DUE TO RECURRENT UTIS AND RECOMMEND RENAL ULTRASOUND TO EVALUATE KIDNEYS DUE TO PAIN AFTER PROCEDURE. ID RECOMMENDS NO ANTIBIOTIC SUPPRESSION AT THIS TIME. PATIENT COMPLAINING OF ITCHING AND IN THE GROIN AREA LIKELY SECONDARY TO YEAST INFECTION. S/P FLUCONAZOLE 150 MG ONE-TIME DOSE. PLAN IS TO DISCHARGE BACK TO FACILITY ON SUNDAY. RENAL US 6/18 MILD BL HYDRONEPHROSIS, REPEAT 6/19 NO CHANGE. COVID TESTING ORDERED TODAY BEFORE GOING BACK TO FACILITY.
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TEXT ASSESSMENT: FORMAT ▸ Problem Representation Statement ▸ Few statements describing hospital milestones ▸ Codes, Major Diagnostic Studies, Completion of Antibiotic Courses, Etc ▸ Closing statement describing overall progression and plans for disposition
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TEXT BETTER? 34-YEAR-OLD WITH NEUROGENIC BLADDER S/P BLADDER RESECTION/ILEAL CONDUIT, RECURRENT UTIS WITH BILATERAL STENTS AND A HX OF DVT/PE S/P IVC FILTER ON XARELTO WHO PRESENTED WITH 2 DAYS OF HEMATURIA, FLANK PAIN, AND FEVER AND WAS FOUND TO HAVE LEFT PYELONEPHRITIS. GIVEN THE PRESENCE OF INFECTION, UROLOGY WAS CONSULTED WHO REMOVED THE STENTS WITH FOLLOW-UP ULTRASOUNDS SHOWING STABLE BILATERAL HYDRONEPHROSIS. ID WAS CONSULTED GIVEN RECURRENT UTI WHO RECOMMEND CEFEPIME FOR A SEVEN DAY COURSE. THE PATIENT’S PAIN HAS RESOLVED AND IS STABLE FOR DISCHARGE BUT PENDING COVID TESTING TO RETURN TO FACILITY.
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TEXT PLAN ▸ For each problem/group of related problems: ▸ Document an assessment/evaluation with justification ▸ Describe active treatment and the response to treatment ▸ Resolve and remove problems which are no longer active
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EXAMPLE: ▸ Acute renal failure ▸ Cr 4.3 ->2.2->1.8 ▸ Monitor I&O ▸ Avoid nephrotoxins ▸ BMP in AM ▸ Acute renal failure ▸ Renal function continues to improve s/p IV fluids and is near baseline. ▸ D/C fluids and repeat BMP in AM
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TIPS AND TRICKS
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TEXT DOCUMENT ALL RELEVANT DIAGNOSES PRESENT ON ADMISSION ▸ Be descriptive: Acuity, Specificity, Severity, Linkage ▸ Don't forget your MVPs: ▸ Obesity (with BMI!) ▸ Sepsis (with Justification) ▸ Renal & Respiratory Failure ▸ Electrolyte Abnormalities
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TEXT ADDITIONAL TIPS ▸ Let PowerChart do her job ▸ Avoid the temptation to over-document ▸ Learn to use dictation (PowerChart Touch)
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TEXT IF YOU LEARN ONE THING ▸ Ditch the phrase “past medical history of” ▸ Us: Active but chronic problems which require management ▸ Coders: Resolved, in the past ▸ Replace with just “with” ▸ Mr. Smith is a 75-year-old with a past medical history of obesity, hypertension and coronary artery disease
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TEXT TIME SAVING ▸ Removing that statement: ▸ 25 characters x5 notes per day x48 weeks per year: 42,000 characters ▸ Average characters per minute: 200 ▸ 211 Minutes Per year
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AUTOTEXT S
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TEXT USE THE “AUTO TEXT COPY UTILITY”
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