Tip: Develop physician training to provide a crash course in documentation basics

The course offers examples of different forms of required physician documentation, including the history and physical (H&P), the progress note, the discharge note, and so forth. Those who have worked in healthcare for some time may think these items are common knowledge for physicians, but Epps says most new physicians “know little about documentation in the beginning. Maybe they have learned that they need to write an H&P and that they need to write a discharge note, but that is as far as it goes. For many physicians this course can be an eye-opener.”

 

The roughly hour-and-a-half computer session not only covers documentation requirements and information about the roles and responsibilities of the CDI staff, it also includes basic information about CMS and the government’s various payment methods. It explains how coders interpret physician documentation notes and translate them into codes, and it explores the various ways different agencies use coded healthcare data for quality, reimbursement, and other purposes. Where appropriate, Epps highlights Emory’s own specific policies and procedures regarding these larger documentation concerns.

 

“Essentially, the course explains why their documentation is important for both business and quality purposes,” says Epps. “We tell them what resources are available to help the residents with their documentation needs and discuss the CDI process. With this course in place, the residents come into the facility with at least a basic familiarity of CDI and its role.”

 

Non-teaching facilities can also consider incorporating a documentation improvement “crash course” for physicians by working with medical staff partners and scheduling some unique training time with new physician staff members.

 

Editor’s Note: This article is an excerpt from “CDI education goes back to school: Training takes creativity,” published in the October edition of CDI Journal.