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.
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