Background: Accurate and timely documentation is essential for patient care, as well as the appropriate reflection of patient complexity and severity of illness. Most hospitals utilize a traditional retrospective or contemporaneous physician-query strategy to ensure documentation accurately impacts performance data, reputation/ranking, and reimbursement.  Purpose: Here, we highlight three unique, hospitalist-driven interventions to support accurate documentation [...]

Background: The observation unit is frequently a destination for patients with yet undifferentiated conditions.  The goal of the observation stay is to complete a crucial diagnostic test or treatment trial that should help specify the diagnosis, but that is not always the case.  Understanding the frequency of diagnoses that remain unspecified after an observation visit [...]

Background: Patient pass-offs represent a known vulnerability in patient care.   The Hospital Medicine Unit at Massachusetts General Hospital has several specialized roles including an admitting hospitalist, a rounding hospitalist, and a nocturnist.  Our on-service time is typically four or five days in a row.  Our hospitalists and nocturnists work in six hour, ten hour and [...]

Background: The daily progress note is the foundation of inpatient documentation and communication for healthcare providers. With the advent of the electronic medical record, copy-and-pasting, note bloat, inconsistencies, erroneous data, and lack of cognitive processing have become widespread leading to difficult to read and inaccurate progress notes.  Purpose: At Bassett Medical Center, it was determined [...]

Background: On October 1, 2007, Medicare changed their payment structure from Diagnosis Related Group (DRG) to Medicare Severity-Diagnosis Related Group (MS-DRG) based reimbursement. This led institutions to prioritize clinical documentation improvement (CDI) programs in an attempt to align healthcare resources with patient complexity. Complete documentation has other benefits to a healthcare system as well. These [...]