• Suhael R Momin, Robert R Lorenz, and Eric D Lamarre.
• Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
• JAMA Otolaryngol Head Neck Surg. 2016 Jun 1; 142 (6): 533-7.

ImportancePhysicians recognize the value of accurate documentation to facilitate patient care, communication, and the distribution of professional fees. However, the association between inpatient documentation, hospital billing, and quality metrics is less clear.ObjectivesTo identify areas of deficiency in inpatient documentation and to instruct health care professionals on how to improve the quality and accuracy of clinical records.Design, Setting, And ParticipantsA single-arm pre-post study was conducted from January 1, 2013, to December 31, 2014, among 17 attending and 12 resident physicians treating 1188 patients at an academic medical center. Data from 1 year prior to the intervention were compared with data for 10 months following the intervention. All increases were analyzed as a percentage increase after the intervention relative to before the intervention.InterventionsAreas for improvement were identified, and all physicians in the department received education on inpatient coding and documentation.Main Outcomes And MeasuresThe capture rate for complications or comorbidities and major complications or comorbidities, the case mix index (the average diagnosis related group relative weight for a hospital or department), and severity of illness and risk of mortality scores.ResultsA total of 1188 inpatients were included in the analysis: 743 in the preintervention period and 445 in the postintervention period. Review of our documentation identified major areas of comorbidity that were frequently underreported. Inadequate nutrition diagnoses (moderate malnutrition, severe protein-calorie malnutrition) were most often underreported. In addition, we found inadequate documentation supporting the presence of neck metastases. Among 1188 patients, the case mix index increased 5.3% (from 2.81 to 2.96) after the intervention, but this was not a statistically significant difference (P = .21). The normalized case mix index increased 21.7% (from 37.3 to 45.4; P < .01). The percentage of patients with a documented complication or comorbidity or major complication or comorbidity increased 27.1% (from 50.2% to 63.8%; P < .01). The percentage of patients assigned a severity of illness score of 3 or 4 increased 24.3% (from 34.7% to 43.0%; P < .01). The percentage of patients assigned a risk of mortality score of 3 or 4 increased 32.1% (from 18.7% to 24.7%; P = .01).Conclusions And RelevanceAfter educational sessions, multiple measures of patient acuity increased significantly owing to improved documentation of common comorbid conditions. Although physicians intuitively appreciate the importance of good documentation, education on the technical aspects of coding can significantly improve the quality and accuracy of clinical records.

28 keywords...

hide…