Background: Clinical documentation is challenging when patients are admitted with many diagnoses of varying severity. Documentation of chronic or low-acuity conditions on the History and Physical (H&P) note can feel less salient than primary admission diagnoses. This can lead to under-documentation of comorbid conditions and an underrepresentation of the complexity of care. Capturing this overlooked complexity has traditionally been the role of medical coders, who query providers about management of comorbid conditions. While these queries certainly generate more work for our clinicians, it has not translated into accurate documentation. As such, our patient complexity, as measured Expected Mortality, is below that of several peer institutions.
Purpose: Our project team found that certain comorbid conditions (i.e., malnutrition, electrolyte deficiencies, anemia, coagulopathy) were disproportionately under-documented on H&P notes. Prior to this intervention, our providers were free to use any H&P template. Through utilization of the Plan, Do, Study, Act (PDSA) model of quality improvement, we investigated the impact of creating a standardized template with the automated capability to recognize selected comorbidities (Figure 1). Thus, we aimed to improve the estimation of Expected Mortality (EM) over a 1-year period without altering clinician workload.
Description: Our team developed a standardized H&P template as an Epic ‘SmartText’ which was made the automatic default for General Medicine admissions. In the initial version (PDSA #1 2020), a block of static text reminded users to document comorbidities as appropriate. In February 2021 (PDSA #2), a Clinical Documentation Integrity (CDI) ‘SmartBlock’ was embedded into the assessment and plan. This tool reviews discrete data from the patient’s record and pulls appropriate diagnoses into the plan with pre-formatted supportive documentation. We also developed a report to monitor use of the template and CDI tool. We made adjustments based on feedback which largely focused on improving user experience and documentation clarity.We had a successful roll-out of the standardized H&P and CDI tool. Compliance by providers was 87%. Capture rates of the selected comorbid conditions increased significantly. (Table 1) EM increased from 2.4% to 3.51%, and Mortality Index (MI) fell from 1.05 to 0.73. Excluding COVID-19 patients, EM still increased to 2.85% and MI to 0.75. When the tool was used, patients had an EM 3.75% and MI 0.69, versus EM 3.25% and MI 0.79 when it was not used.
Conclusions: These data suggest that a standardized H&P template with automated diagnosis detection and documentation prompts can increase the documentation of commonly overlooked comorbidities. As such, it can help providers document more accurately and capture the complexity of their patients without adding excess documentation time and without increasing the query volume for providers.