Guest Post: Getting physicians to document effectively
by Timothy N. Brundage, MD
Physicians resist change. They fear it. Although comfortable reading medical literature, and comfortable improving patient care with new techniques and medications, having CDI professionals “educate” physicians about improving their documentation habits makes them markedly uncomfortable. Physicians see such discussions and reviews as a threat to their autonomy. They view CDI efforts as the “evil administration” pushing them to document differently, which of course, adds to their discomfort.
Regardless of previous experiences with documentation efforts and regardless of the additional effort it may necessitate, physicians’ response and cooperation is required. Why? Because unfortunately, physician scrutiny is increasing.
In summary, physician documentation is critical for MS-DRG capture and assignment of a relative weight as well as an expected length of stay. Physician documentation begins with legible handwriting and moves to accurate diagnosis and effective management of patient care issues. Consider recommending physicians use a pocket CDI card for accurate diagnosis. Download a sample pocket CDI card here.
Editor’s Note: Brundage, at the time of this article's original release, was an ACDIS Advisory Board member and physician champion for Kindred Hospital North Florida District in St. Petersburg, Florida. This article was originally published as the “Featured Article” on the ACDIS homepage, February 4, 2013.