Background: Clinical Documentation Improvement programs have been present in adult hospitals for many years. These programs strive to promote clinicians working together with nurse specialists to appropriately depict the care delivered and increase coding accuracy. This collaboration has traditionally been through written and verbal documentation queries that clarify diagnoses based on a patient’s clinical indicators and risk factors. The transition to ICD-10 made these programs even more important as coding professionals require more detailed documentation to code claims and submit bills. In our independent, non-university affiliated children’s hospital, we initiated an inpatient clinical documentation improvement program in March 2017. As with any new change, providers were hesitant and slow to adapt to answering queries.
Purpose: To improve provider engagement, we sought to enhance clinical documentation queries by adapting hospital-approved definitions of the diagnoses that were previously identified to be the most poorly documented. Hospital-approved definitions were formed by creating work groups of key stakeholders in the departments impacted the most by these diagnoses. For example, the definition of acute respiratory failure was determined by a work group consisting of pediatric pulmonologists, intensivists, and hospitalists.
Description: Once hospital-approved definitions were determined, our clinical documentation specialists use them in their electronic health record based written queries or in verbal queries during rounds. Metrics are tracked including provider response rate, agreement rate, and disagreement rate. Surveys were performed with hospital medicine providers who answer inpatient clinical documentation queries to help determine success of this intervention.
Conclusions: Throughout the program, our providers have had a high monthly response rate to queries, 93.2%-100%. With the institution of hospital approved definitions within the queries and clinical documentation specialists being more present on the floor by June 2017, our physician agreement rate has increased, and our physician disagreement rate has decreased. Surveys of pediatric hospital medicine providers noted that 66.7% (12/18) felt that the most helpful provider engagement performed by the program was the hospital-approved clinical definitions being placed within the queries themselves followed by 22.2% (4/18) who felt that the clinical documentation team talking to the section as the most helpful.
We feel that this innovative approach to improving clinical documentation has prompted our providers to better embrace the need to further specify controversial clinical diagnoses in their documentation. Our clinical documentation nurse specialists are better able to provide the translation between providers and coders that is needed in today’s ICD-10’s standards. We strive to continue to develop further interventions to continue to enhance our clinical documentation improvement program’s provider engagement.