Guest Post: Accurate documentation for terminal patients

by Trey La Charité, MD

Sadly, there are patients who will not survive their current level of illness regardless of the best efforts of their physicians and their medical facility. The providers caring for these patients are often at risk of  underreporting those patients’ severity of illness and risk of mortality.

CDI professionals must educate facilities and physicians about the importance of accurately capturing the entire disease process  description because physicians, unfortunately, are frequently reluctant to document additional disease  processes in the charts of patients who are obviously about to die. Let’s look at one example before discussing possible causes.

A CDI specialist reviews a case on the floor or in the ICU and notices “prognosis grim” written several times in the medical record. The physician, however, neglected to document one or more strikingly  obvious diagnoses from the patient’s record. The CDI specialist queries the physician about the absent disease processes, asking whether those diagnoses are present and how they might affect the patient’s  current clinical situation. The queries go unanswered. The CDI specialist follows up with the physician, which proves unproductive.

The physician replies, “I’m not going to write that. That patient is about to die.” There are numerous reasons physicians take this position, and while this is not an exhaustive list, you may have heard some of these excuses at one time or another:

• “I don’t want to ‘penalize’ the patient.”
• “I don’t want to bilk the insurance company.”
• “I don’t want to stick the family with a higher bill.”
• “It just doesn’t feel right.”
• “Why do you need that? They are going to die. How much sicker do you need them to look?”

By examining the faulty and misguided rationale behind these excuses, we can develop an appropriate response when confronted with a similar situation in the future.

Your providers are not “penalizing” the patient. When properly documented, the principal diagnosis and the circumstances leading to the current medical situation are firmly established in the medical record. There is no penalty to the patient for accurately describing how sick he or she is. On a personal note, I believe patients’ families gain some solace, if they choose to review the records, from the documentation
of the severity of their loved one’s illness simply by knowing the full extent of the condition.  Furthermore, there is a clear benefit from an epidemiological standpoint to tracking disease processes  and identifying the toll those diseases take on our society.

Providing diluted documentation related to the severity of a patient’s illness also dilutes our ability to provide that larger societal insight. As  providers, our job is to take care of those patients to the best of our abilities. If we do not have a clear and inclusive picture of the various factors that play a role in a patient’s potential recovery, how can we effectively manage that patient in the hopes of providing a reasonable outcome?

Editor’s Note: This article is an excerpt from the April 2013 edition of CDI Journal. La Charité, at the time of this article's original release, was a hospitalist with the University of Tennessee Hospitalists at the University of Tennessee Medical Center at Knoxville, and an ACDIS Advisory Board member. He is board certified in internal medicine and has been a practicing hospitalist since 2002.