Improving Clinical Documentation of Evaluation and Management Care and Patient Acuity Improves Reimbursement as well as Quality Metrics

OBJECTIVE Accurate clinical documentation is foundational to any quality improvement endeavor as it is ultimately the medical record that is measured in assessing change. Literature on high-yield interventions to improve the accuracy and completeness of clinical documentation by neurosurgical providers is limited. Therefore, the authors sought to share a single-institution experience of a two-part intervention to enhance clinical documentation by a neurosurgery inpatient service. METHODS At an urban, level I trauma, academic teaching hospital, a two-part intervention was implemented to enhance the accuracy of clinical documentation of neurosurgery inpatients by residents and advanced practice providers (APPs). Residents and APPs were instructed on the most common neurosurgical complications or comorbidities (CCs) and major complications or comorbidities (MCCs), as defined by Medicare. Additionally, a “system-based” progress note template was changed to a “problem-based” progress note template. Prepost analysis was performed to compare the CC/MCC capture rates for the 12 months prior to the intervention with those for the 3 months after the intervention. RESULTS The CC/MCC capture rate for the neurosurgery service line rose from 62% in the 12 months preintervention to 74% in the 3 months after intervention, representing a significant change (p = 0.00002). CONCLUSIONS Existing clinical documentation habits by neurosurgical residents and APPs may fail to capture the extent of neurosurgical inpatients with CC/MCCs. An intervention that focuses on the most common CC/MCCs and utilizes a problem-based progress note template may lead to more accurate appraisals of neurosurgical patient acuity.

Download Full-text

Structured Reporting of Medical Findings: Evaluation of a System in Gastroenterology

Methods of Information in Medicine ◽

10.1055/s-0038-1634885 ◽

1992 ◽

Vol 31 (04) ◽

pp. 268-274 ◽

Cited By ~ 24

Author(s):

W. Gaus ◽

J. G. Wechsler ◽

P. Janowitz ◽

J. Tudyka ◽

W. Kratzer ◽

...

Keyword(s):

Structured Data ◽

Structured Reporting ◽

Free Text ◽

Clinical Documentation ◽

Abdominal Sonography ◽

Technical Examination ◽

Medical Reports ◽

Time Required ◽

Upper Abdominal ◽

Structured Approach

Abstract:A system using structured reporting of findings was developed for the preparation of medical reports and for clinical documentation purposes in upper abdominal sonography, and evaluated in the course of routine use. The evaluation focussed on the following parameters: completeness and correctness of the entered data, the proportion of free text, the validity and objectivity of the documentation, user acceptance, and time required. The completeness in the case of two clinically relevant parameters could be compared with an already existing database containing freely dictated reports. The results confirmed the hypothesis that, for the description of results of a technical examination, structured data reporting is a viable alternative to free-text dictation. For the application evaluated, there is even evidence of the superiority of a structured approach. The system can be put to use in related areas of application.

Download Full-text

Computer-Aided Diagnosis in Jaundice: Comparison of Knowledge-based and Probabilistic Approaches

Methods of Information in Medicine ◽

10.1055/s-0038-1634634 ◽

1996 ◽

Vol 35 (01) ◽

pp. 41-51 ◽

Cited By ~ 3

Author(s):

F. Molino ◽

D. Furia ◽

F. Bar ◽

S. Battista ◽

N. Cappello ◽

...

Keyword(s):

Clinical Presentation ◽

Clinical Information ◽

Diagnostic Value ◽

Clinical Findings ◽

Clinical Documentation ◽

Data Set ◽

Knowledge Based ◽

Number Of Patients ◽

Support Tools ◽

Aided Diagnosis

AbstractThe study reported in this paper is aimed at evaluating the effectiveness of a knowledge-based expert system (ICTERUS) in diagnosing jaundiced patients, compared with a statistical system based on probabilistic concepts (TRIAL). The performances of both systems have been evaluated using the same set of data in the same number of patients. Both systems are spin-off products of the European project Euricterus, an EC-COMACBME Project designed to document the occurrence and diagnostic value of clinical findings in the clinical presentation of jaundice in Europe, and have been developed as decision-making tools for the identification of the cause of jaundice based only on clinical information and routine investigations. Two groups of jaundiced patients were studied, including 500 (retrospective sample) and 100 (prospective sample) subjects, respectively. All patients were independently submitted to both decision-support tools. The input of both systems was the data set agreed within the Euricterus Project. The performances of both systems were evaluated with respect to the reference diagnoses provided by experts on the basis of the full clinical documentation. Results indicate that both systems are clinically reliable, although the diagnostic prediction provided by the knowledge-based approach is slightly better.

Download Full-text