The Quality Review

CDI Quality Review

Guided by the mission of CDI, ethical stewardship and a moral obligation to the person under care, a quality review of the medical record is the vehicle by which we move forward, for without that, clinical documentation integrity doesn’t exist.

This blog outlines not a review for quality (as in quality measures, or SOI/ROM), but a review that, at its core, is quality.

Clinical documentation integrity is driven equally by clinical and coding concepts. This is the reality in today’s healthcare landscape, and to abide by one or the other to a lesser degree is short-changing oneself as well as the patient by providing a lessor quality review.  In fact, a quality record review uses all official coding and documentation guidelines applicable to the setting, whether this is the ICD-10-CM, ICD-10-PCS, CPT, HCPCS Level II, the UHDDS, UACDS, and the Documentation Guidelines for Evaluation and Management Services.  For the purposes of this blog, the focus will be upon the inpatient hospital medical record review, although the majority of the information can be extracted for an outpatient medical record review.

Beginning with the question some may be asking, “What do I need to review?” Good question, with the answer being found in the ICD-10-CM Official Coding Guidelines for Coding and Reporting, “The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”

The logical way to review a record is to start from the beginning; not the first page, but when the person entered the hospital.

One often hears about the chief complaint/presenting problem/reason for visit, and for good reason because it can help determine the principal diagnosis.  However, it is equally important to also ask what needs to happen before the patient can be safely discharged.  Think through the entire encounter process and begin with the end in mind, for that is what the provider is considering.  In order to capture the essence of the provider’s thought process, it is crucial to follow an “encounter driven review”.  As the provider moves through the encounter using critical thinking, so too should the CDI professional. A quality review confirms that the CDI professional is continually asking questions.

Most hospital admissions begin with a visit to the emergency room; therefore, it makes sense to start there:

  • Look at the triage and nurses notes for items such as the documented response to treatments or the skin assessment, for example
  • The chief complaint noted by triage is often comprised of signs and symptoms but this will frequently give clues to the principal diagnosis
  • Note the initial and trending vital signs
  • Note the date and time of the admission order. This could be the difference between a PSI or not, such as in the case of a fall with fracture that occurs in the emergency room.
  • Look for clues to validate diagnoses that may be documented in the H&P or consults
  • Don’t forget to look at notes from pre-hospital care, i.e., the ambulance, helicopter or airplane

Medications ordered and administered:

  • This is a continual process, not only in the ED but throughout the entire record.
  • This should be a part of the daily review

Labs, diagnostics, procedures:

  • Carefully review all of the above, noting both normal (could help rule out a diagnosis) and abnormal (could help validate a diagnosis or serve as a clinical indicator in a query) findings
  • This should be a part of the daily review

Additional provider notes (progress notes, consult notes):

  • The most important tip is to read every note in its entirety; a lot could happen in the 23+ hours since the last record review
  • Note if the documentation is in accordance or conflict with the attending’s note; query the attending if there is a conflict
  • Not every perceived conflict is one according to the guidelines and coding clinic. For example, if the attending documents “CHF”, and cardiology documents “acute HFrEF”, this is not conflicting documentation; it is documenting specificity and a code for “acute HFrEF” should be assigned
  • This should be a part of the daily review

Nurse’s notes are another area where scrutinization is necessary for a complete picture:

  • Clinical indicators and validation for documented diagnoses/conditions can often be found here
  • Look in the nurse’s notes for patient response to treatment (medication, fluids, procedures, etc)
  • Because nursing documents by exception with the advent of the EMR, pay particular attention to entries that stand out from the norm – these could contain especially valuable information
  • This should be a part of the daily review

Other clinical team notes (nutrition, wound, respiratory, pharmacy, PT/OT, etc):

  • These notes are invaluable for painting the picture
  • Note if the documentation is in accordance or conflict with the attending’s note; query the attending if there is a conflict
  • Not every perceived conflict is one according to the guidelines and coding clinic. For example, if the attending documents “sacral pressure ulcer POA”, and the wound team documents “stage 3 sacral pressure ulcer”, this is not conflicting documentation; it is documenting specificity and a code for “stage 3 sacral pressure” should be assigned with the POA indicator of “Y”.
  • This should be a part of the daily review

Moving lastly to the H&P, this should be approached with a provider’s lens as well.  Don’t skip to the documented diagnoses.  Reading the assessment and plan before the remainder of the H&P could lead your mind to rule out other possibilities as it focuses on the documented diagnoses.

  • Ensure conditions carried over from the ED, especially those conditions that were treated and/or resolved in the ED
  • Looking at the PMH, are there any conditions that were not included in the ED
  • Have all diagnoses/conditions been documented to their known specificity?
  • History and physical exam: note both normal (could rule out a diagnosis) and abnormal findings (could help validate a diagnosis or serve as a clinical indicator in a query).

A quality review consists of continual clinical validation as well as gap assessment.  A CDI professional must validate all documented conditions/diagnoses with each review, as well as assess for any gaps in documentation and clarify those gaps.  This is at the core of the profession.

It’s all about quality over quantity.  If a CDI professional is tasked with a quality review, adequate time should be allotted to do right by the facility, the provider, and most important, the patient.

Respectfully,
Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP
Director of CDI Education

 

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