Background: Clinical documentation integrity (CDI), a process by which documentation is optimized to be both congruent with Centers for Medicare and Medicaid (CMS) terminology and reflect patient severity of illness, is widely used in healthcare to ensure appropriate coding for hospital reimbursement and improve accuracy of research and quality outcomes. CDI optimization is often performed [...]

Background: With the advent of the Electronic Medical Record (EMR), documentation occupies up to 50% of doctors’ time1 and prior work has revealed that internal medicine residents spend more than four hours daily on documentation2. Secure messaging (SM) has been recently integrated into the inpatient EMR system, allowing healthcare team members to directly message physicians; [...]

Background: Early sepsis recognition and treatment can save lives. The Centers for Medicare & Medicaid Services defines appropriate treatment using the Severe Sepsis/Septic Shock Early Management Bundle (SEP-1) components. To help improve sepsis identification, documentation, and organizational compliance with SEP-1, our hospital implemented a “best-practice alert” (BPA) comprised of Epic’s “sepsis score,” but the rates [...]

Background: The Discharge Summary (DS) plays a vital role in transmitting key information about a patient’s hospital admission to their primary care clinician (PCC) and serves as a valuable information source for inpatient clinicians. However, current guidelines for DS creation tend to neglect the importance of prioritizing critical content. This oversight, coupled with the excessive [...]

Background: Clinical documentation is essential for adequate representation of patient quality care metrics and accurate diagnosis capture but rarely taught in graduate medical education. Inaccurate capture of diagnoses leads to clinical documentation integrity (CDI) queries, which increase workload on busy providers. Implementation of a standardized note template for our resident physicians previously resulted in an [...]

Background: Clinicians spend nearly half of their time at work on clinical documentation, impacting time spent with patients and trainees. Studies have demonstrated a correlation with electronic health record (EHR) documentation burden and clinician burnout. Finding innovative ways to balance increasing EHR demands and mitigate this burden is essential. Purpose: We identified that time spent [...]

Background: Diagnose and treat. That is the role of the physician. But the practice of medicine in recent years has been beaten hollow; its patient mission eclipsed by unwieldy technology and its practitioners so inundated with documentation and data entry, resulting in disengaged, frustrated, and burned out clinicians. The hospitalist has access to the entirety [...]