Guest Post: Tips for winning support from nurses

by Linda Renee Brown, RN, MA, CCDS, CCS, CDIP

While physician documentation drives our CDI and HIM programs, we nevertheless need the assistance of our facility’s nurses and their nursing documentation. Not only are nursing notes and assessments incredibly helpful in formulating physician queries and providing supporting clinical evidence for physician diagnoses, but sharp auditors are going to notice—and question the consistency of the medical record—if physician and nursing documentation doesn’t match up.

Contributions (some obvious, some maybe not so obvious) that nursing notes can provide our CDI process include:

• Documentation of the stages of pressure ulcers. The physician has to document the ulcer, but the nurse can stage it, and, of course, stage III and IV pressure ulcers which are present on admission (POA) are considered MCCs. Educate nurses on the critical role they play in this regard. I don’t know how it is for you, but in my experience, the admitting physician isn’t always thinking about or looking for pressure ulcers. Nursing documentation of pressure ulcers at the time of admission will support a POA query, and thus help to avoid coding the pressure ulcer as a hospital-acquired condition (HAC).
• BMI. Nursing (or dietary) documentation of a patient’s body mass index (BMI) can be linked to a related diagnosis, such as morbid obesity, which allows for either a low or high BMI to be coded as a CC. Severely underweight and overweight patients require a disproportionate amount of hospital resources. Heavier patients may need special equipment and additional staff to meet their physical needs. Very underweight patients may have low functional reserves and intensified dietary requirements. Both of these patient populations may be more likely to experience a longer healing process after surgery and a corresponding longer hospital stay.
• Atelectasis. This is another CC that increases length of stay and is often under documented by physicians. Look for nursing documentation of weak cough effort, poor performance on incentive spirometry, resistance to ambulation, diminished breath sounds, or an unexpected temperature spike.
• Functional quadriplegia. Encourage nurses to document in their assessment the patient’s mental status and a description of the patient’s ability to use their extremities; that documentation can provide a supporting basis for your physician queries.
• Catheter-related UTI. Appropriate documentation may help the facility to avoid another HAC, but possibly even improve the patient’s DRG assignment. Remind nurses to document the presence of any indwelling catheter (not just Foleys, but also suprapubic and nephrostomy tubes) in their admission assessment, as well as an evaluation of the urine quality and the patient’s urinary symptoms at the time of admission.
• Vascular catheter infections. Again, nurses may find the infected insertion site before the physician does. Encourage them to document what they see.
• Acute blood loss anemia (ABLA). Encourage nurses to be precise in their documentation of chest tube or surgical drain output, as well as hemoptysis/hematemesis or saturated wound dressings, so you can include that clinical information with the low hemoglobin and hematocrit (H/H) when you decide to query for ABLA.
• Mechanical ventilator duration. Recovery Audit Contractors (RAC) are catching facilities that bill into DRG 207 or 870 (continuous invasive mechanical ventilation for 96 consecutive hours or more with a respiratory or sepsis principal diagnosis) for not calculating the hours correctly. It’s not always clear from physician or respiratory therapy records when the patient goes on or off a ventilator, especially when there are extended weaning trials. ICU nurses should be diligent about documenting the time of intubation, extubation, and the exact times when the patient is on the vent or being weaned. They should also understand the importance of noting the use of T-pieces for trached patients.

As a CDI specialist, when I push the computer cart from nursing station to nursing station, I can pick up a lot of information just by listening to the nurses, or by asking them questions about a particular patient. They are invaluable resources to the CDI specialist, because they are with the patient 24/7, unlike the snapshot moments the patient has with the physician. When nurses understand how they can help the CDI program, most are very willing and eager to participate. So, don’t forget them!

Editor's note: Brown, at the time of the article's original response, was an independent CDI consultant based in Carrollton, GA. With experience in critical care, nursing education, disease management, case management, and long-term care, she has worked as a CDI specialist, educator, director, and consultant. She is a frequent writer on topics involving clinical documentation and published her own "The Case Manager's Quick Guide to Diagnostic Related Groups" in 2013.