How to Review a Record: One Document at a Time

How to Review a Clinical Record

 

I subscribe to an encounter-driven review, where one follows the provider’s critical thinking process during the encounter.  All clinicians follow a critical thinking-based assessment strategy. The critical thinking begins with the first strand of information and progresses to the plan.  In an encounter-driven review, the record is permitted to unfold without preconception and all diagnoses are considered as the record review reveals a diagnosis to be ruled in, ruled out, or possible.

An encounter-driven review characteristically describes a review where everything is reviewed. Although, if more guidance is desired, you can look to the Official Guidelines for Coding and Reporting. This is where the introduction states, “The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated”.  In order to review the entire record, one must start at the beginning.  This blog post outlines the hospital admission process, starting with a visit to the emergency department.

 

Emergency Department

Regardless where treatment begins, the goal is stabilization. So, you’ll notice vital clues and treatment information will frequently appear in pre-hospital (ambulance, urgent care) notes.

Once in the emergency department, the triage notes will provide clinical evidence about the appearance on presentation, documented response to treatments and skin assessment.  It’s just as important to note the presenting vital signs as well as the trending vital signs, as they will reveal a more complete story.  The chief complaint is often comprised of signs and symptoms and frequently provides clues to the principal diagnosis.  The emergency department notes will provide clinical evidence-valuable in clinical validation for documented diagnoses-as well as identifying gaps as the record review process continues.

 

Medications

Some EHRs are designed for the provider to select an associated diagnosis, instead of signs and symptoms, for each medication from a drop-down.  This is best practice and usually requires a CDI and HIM representative at table discussions with IT.  Medications should be part of the daily review process because new and single dose medications can be identified, as well as medications which were held or prn medications that were administered.

 

Diagnostics

Carefully review all labs and diagnostics as part of the daily review, noting both normal (which could help rule out a diagnosis) and abnormal findings (which could help validate a diagnosis or serve as clinical evidence in a query).

It’s important to note the date in an EHR.  The columns align next to each other from encounter to encounter and it’s easy to have data from a previous encounter brought into the current encounter’s record, especially if patient is re-admitted within days, or admitted the same month in the previous year.

Note any specificity described within the report since coding clinic allows the coding of specificity from a diagnostic report provided the diagnosis has been documented by the provider.

 

Nursing and Ancillary Notes

A daily review of nursing and ancillary notes can provide clinical evidence, which is valuable in clinical validation for documented diagnoses as well as identifying gaps.

Look in the nursing notes for patient response to treatment (medications, fluids, procedures, etc).  Pay particular attention to nursing notes that stand out from the norm because the EHR often directs documentation by exception.

Nutrition notes often contain clinical evidence that can validate the diet status as well as the degree of malnutrition, if appropriate.

Wound care notes provide clinical evidence which can validate the presence of a wound as well as provide specificity regarding the type, stage, and site.  Remember to query for clarification if there is conflicting documentation between the provider and wound care team.

Respiratory notes are invaluable because respiratory therapists are often early responders to a scene where standing orders permit certain treatment which can often resolve signs and symptoms before the provider arrives.

In addition to those listed above, it’s crucial to look in all notes for documentation of pressure ulcer stage and non-pressure ulcer depth, BMI, coma scale and NIH Stroke Scale because documentation of those items may come from any clinician who is involved in the care of the patient (Official Guidelines for Coding and Reporting I.B.14).

A new addition to this guideline is the addition of categories Z55-Z65, persons with potential health hazards related to socioeconomic and psychosocial circumstances.  While this documentation can be found anywhere in the medical record, a good place to begin is the case manager and/or social worker notes.  The ‘any clinician’ rule applies here as well.  Note that all of these codes are to be assigned as secondary codes only.

 

Provider Notes

In an encounter-driven review, the history and physical is the last document analyzed in the initial review, with the ongoing provider notes analyzed last in subsequent reviews.  When reviewing any provider notes, whether history and physical, daily notes, or consult notes, remember to follow the encounter flow.  Review these documents from beginning to end so as not to miss valuable clinical evidence.

Remember, the principal and secondary diagnoses are defined as ‘after study’; therefore, what may have been considered on admission may go down a different pathway after careful study of the record closer to discharge.

 

Problem List

While the original intentions of a problem list are admirable, today’s problem list can be seen as either an asset when the conditions are succinct with a clear start and/or end date, or a liability that raises more questions than provides answers.  Resolution of the concerns with the problem list requires a team approach and a record review is one approach that could identify such concerns.

My goal in this blog is to outline one recommendation for a record review process, although best practice is to follow your facility policy for record review. These suggestions should be used in accordance with the Official Guidelines for Coding and Reporting, Coding Clinics, best practice clinical evidence and the query practice briefs published by AHIMA and ACDIS/AHIMA.

 

Wishing you success in CDI!

Respectfully,

Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP

Director of CDI Education

MedPartners

 

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