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More than 50% of cases had opportunities for coder and/or physician education to improve data capture or documentation, impacting quality metrics and data.
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More than 25% of cases resulted in an increase in weighted cases and affected potential funding.
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Fewer than 25% of the cases revealed no opportunities for improvement.
Health Information Systems
Clinical documentation improvement (CDI) facilitates an accurate representation of the care provided through complete and concise reporting of diagnoses, comorbidities and procedures to ensure the acuity and complexity of the patient’s care is available to be coded.
It is crucial that hospitals accurately reflect the level of patient acuity in the medical record to ensure proper data, resource use, and appropriate funding.
What you need to know about clinical documentation improvement
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High-quality documentation = high-quality dataOften the challenge for the coder is to convert the clinical terminology into diagnostic terms, assess significance and assign the appropriate diagnosis codes.
3M has found that medical documentation in over 50% of charts is not clear, specific or accurate, often due to missing or incomplete information.*
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Documentation in the chart and the corresponding coded data is used for patient quality and outcome metricsData is used to determine the ELOS, the hospital’s mortality rate, infection rate, and other quality indicators, all of which are publicly reported or benchmarked against other hospitals for comparisons. Comprehensive documentation is required to ensure that the data is a true reflection of hospital performance.
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Accurate data leads to appropriate funding for the acuity of service provided and resource consumptionPhysician documentation drives case mix groups and clinical codes that determine funding allocation for the hospital. Therefore reflection of the true acuity of the patient will ensure appropriate compensation for the care provided.
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Successful CDI programs appoint a CDI specialistCDI specialists conduct in-depth chart reviews and work with physicians to ensure the documentation fully reflects the patient’s episode of care. 3M are experts in training CDI specialists so they make an immediate impact in their role. The return on the investment for this high-quality training has proven to exceed customer expectations.*
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Patient records
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Clinical coding
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Hospital data
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Reporting
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Funding
* Data available on internal file.
Products and services for clinical documentation improvement
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Understanding the deficiencies in documentation and/or coding within a health care organization is the first step in identifying the need and requirements for clinical documentation improvement. -
Customized education for CDI specialists and/or coders to make every medical record more accurate and valuable. Includes training regarding chart review, implementation/monitoring of the query process and analysis of data to effectively run a CDI program. -
A successful CDI program requires physician involvement, and support is critical. Effective communication and collaboration between the physicians and CDI team is key. 3M offers customized physician training on documentation improvement in class or via online video. -
A software tool integrated with your abstracting system for CDI specialist and coder workflow. Standardizes and manages the query process and reports, while capturing impact on case mix and outcomes. Includes 75 query templates for physician documentation clarification. -
Web-based searchable tool for CDI specialists, physicians and coders, to ensure specificity and accurate documentation of key conditions. Streamlines documentation, enables complete code assignment and assists with chart reviews. -
3M™ M*Modal CDI Engage™ System uses artificial intelligence (AI) and natural language understanding (NLU) technology to embed proactive clinical intelligence into front end physician electronic health record (EHR) workflows.
Recent chart audits and studies done by 3M Canada Health Information Systems staff in Ontario show that more than 50% of medical records could be improved with more complete and accurate documentation.
These gaps are important opportunities for physicians and/or coders to improve data capture and documentation, leading to improved quality metrics and potential funding.
Findings
>50%
<25%
>25%
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A minimal number of clinicians are aware of the link between clinical documentation and accurate funding.
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Lack of understanding was the #2 reason for clinicians not replying to the coding department.
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No medical courses at a tertiary level have formal training on clinical documentation.
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Clinical Documentation Improvement Specialist Program
3M and CHIMA have partnered to deliver an online Clinical Documentation Improvement Specialist Certificate Program. This program is open to experienced health care professionals wishing to become CDI specialists.
Learn more about the course and how you can register.
