Background:
Appropriate documentation of Congestive Heart Failure (CHF) specificity is still a major documentation problem in most hospitals in the United States despite the frequent presence of Clinical Documentation Improvement Specialists (CDIs) to assist with chart reviews and appropriate documentation/coding. We are a large hospitalist division providing care at 2 large tertiary care facilities in an urban/suburban setting. We have access to review performance metrics regularly. Group and individual meetings with CDIs occur quarterly hence this afforded us the opportunity to carry out chart reviews frequently.
Purpose: Upon evaluation, our performance on CHF specificity remained poor despite regular reviews (<50% CHF specificity). Moreover, the advent of ICD- 10 obviated the need for a change. Our division sought to analyze the documentation ourselves to help identify the barriers and create initiatives to promote the necessary changes.
Description: An audit tool was created and a 60 chart retrospective review was performed on hospitalist charts identified by the CDIs as not having CHF specificity. The audit was completed in one day by giving every hospitalist 2-3 charts. Surprisingly, our review uncovered that nearly 50% of the patients identified by the CDIs as persons with CHF, actually had no clinical evidence of such. For 45%, opportunities for specifying CHF had been missed. For the remaining 5%, documentation of specificity had in fact been present. These finding were presented to the CDIs department.
Conclusions:
A combination of a copy forward feature in our EMR and the over categorization of CHF were identified as the predominant culprits. For the hospitalists, topic specific noon conferences were given, a templated progress note that optimized documentation was rolled out and individual performance on CHF specificity is provided transparently to the entire group regularly. Subsequent reviews of the division’s performance have shown a significant improvement in CHF specificity, with over 60% at one site and over 70% at the other. This improvement has been sustained for almost a year.
Taken together, our data shows improved documentation specificity and coding happens when both the hospitalists and the CDIs are educated. Looking at the documentation yourself may help identify additional explanations for poor performance.