Radio Recap: Anatomy of a surgical note
Though 93% of respondents to an ACDIS Radio poll review surgical and operative notes, this area can pose a daunting hurdle for CDI teams, said Frances Frank, RN, MBA/MSN/HCM, CPHQ, manager of CDI at Stanford (California) Health Care, on the March 22 episode, “ACDIS conference preview: Anatomy of a surgical note.”
“The more surgical and operative notes people review, the better they become” at the task, she said. “Our work is transforming. Our whole industry is transforming,” and CDI specialists need to be proficient at all types of record review in order to keep up, said Frank who joins Cheryl M. Manchenton, RN, BSN, CCS, senior inpatient consultant/project manager with 3M Health Information Systems on stage at the 10th annual ACDIS conference, May 9-12, in Las Vegas, Nevada.
CDI specialists need a firm understanding of anatomy and physiology, to delve into extremely technical surgical notes, Frank said. Although additional training isn’t necessary for the CDI staff at Stanford because surgical documentation reviews are considered part of their original, typically assigned duties, she said.
CDI staff also need a positive attitude, and thick-skin, since physician engagement often proves the most difficult component of such reviews. Building relationships with the physicians, however, can help ease some of the tension, Frank said. One way to encourage relationship building is to “tap into the physicians’ desire to teach,” Frank said. “Surgeons love to teach and one way that can happen is by asking them ‘can you help me understand?’”
Surgical note templates often lead to coding confusion—the complication section especially so—so it also represents an area where CDI staff can step in and help, according to Frank. Surgeons often think that listing a condition as a complication equates to fault—that he or she did or didn’t do something during the surgery that led to an unplanned complication of the patient’s care.
“Working with the surgeons and proceduralists on updating the templates was essential,” for buy-in at her facility, Frank said. Clarifying those templates can help make the physicians’ and the CDI specialists’ lives a bit easier.
Template improvement aside, Frank suggested approaching surgical CDI reviews from the aim of truly complete and accurate documentation. “It’s not only about querying so we can capture the codes. It’s about making sure the note is as clear as possible about what actually happened during that procedure,” said Frank.
Frank and Manchenton plan to dig into surgical and operative chart reviews more deeply during their presentation at the 10th annual ACDIS conference on Day 2 in Track 1.
“We’re being playful with the presentation and excited to help people see things creatively,” Frank said. “I hope the audience will see the fun in it as well. We’re promising a good time in Las Vegas!”
Editor’s Note: To listen to the complete ACDIS Radio show from March 22, “ACDIS conference preview: Anatomy of a surgical note,” click here. To read the Q&A with Frank’s co-presenter, Cheryl Manchenton, click here. To read an article about query and education opportunities in surgical documentation, click here.