Guest Post: It takes a hospital..

by Sylvia Hoffman, RN

A recent hospital audit of 300 medical records turned up some not too surprising facts about physicians. The doctors are still not documenting appropriately, their handwriting is illegible, and the discharge summaries are inadequate.

Recent changes in CMS regulations have made certain wording and diagnosis linking imperative for hospital coding and reimbursement. The new rules are confusing and complicated. Certain words need modifiers, certain diagnosis must be linked to their causative agents, other conditions must be rated as acute, exacerbated, or unstable.

There is an old expression that “You can’t teach an old dog new tricks.” I am starting to wonder if this shouldn’t also include physicians. I work in the Clinical Documentation Improvement office and we strive to educate physicians on the nuances of clinical documentation. This recent  audit indicates that we still have a lot of work to do.

I attended parochial school my entire life and I spent most of my formative years having to stay after school for poor penmanship. I still have terrible handwriting and I missed out on a lot of fun. This only goes to explain why I cannot criticize someone for having poor handwriting. The new computer era is upon us and with the advent of electronic medical records it also may be a mute point. I do not give penmanship classes.

However, like that old dog, the problem may be that seasoned physicians are too old to learn new techniques for documenting patient care. Perhaps we need to start educating the physicians sooner, when they are still in medical school.

The problem may be the lack of incentive. Perhaps the physicians need some sort of pay for performance to entice them to change their old habits.

Or the problem may be that hospitals need more upper management support for their CDI departments. Perhaps a series of speeches given by the CEO would get everyone motivated.

The problem may be a lack of educational resources. Perhaps hospitals should invest in teaching tools and educational literature.

The problem may be everything mentioned above and then some.

Clinical documentation teams across the country are working diligently to educate physicians and improve documentation. Blaming the CDI department for the deficiencies of the physicians, will not correct the problem. Secretary of State Hilary Clinton said “it takes a village to raise a child,” cribbing from an old African proverb. Well, maybe it takes a hospital to educate a physician.

Editor's note: Hoffman, at the time of this article's release, was a CDIS in Tampa Florida. She has been a nurse for more than 20 years and enjoys writing, painting, and travelling.