Guest Post: Take 10 steps to refresh your documentation review process

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

I recently had occasion to stop and think about how I approach a chart for a clinical documentation review. For me, it has become an almost instinctual process, so I found it instructive to examine my process in a more systematic manner. With that in mind, I thought I would share my perspective on how to approach a review.

I recommend a review methodology that goes from door-to-door: beginning with the ED record and ending with the discharge summary. As you review the chart, think about the disease processes you see. If you are an RN CDI professional, think about this just as if you were taking care of that patient on the nursing unit. Consider how these disease processes interrelate and affect that patient’s care. Now you need to make that clinical picture fit the regulatory requirements through compliant, codeable language.

Step 1: Review the ED physician record. Note presenting signs and symptoms, lab values, medical history, and the ED physician’s impression, as well as the reason why the patient is being admitted. Note any diagnostics or procedures performed in the ED. Don’t forget this part of the admission, because you might be using the ED record as the basis for an attending query, such as acute respiratory failure for a dyspneic patient intubated in the ED.

Step 2: Look for the physician’s document of the patient’s history and physical (H&P). Use the same review strategy you used for the ED record. Determine if the physician has a clear idea of the principal diagnosis. Identify if the physician is waiting for additional diagnostics or consults. Take note of any gaps in the documentation. Can each diagnosis be coded completely based on the documentation? How firm is each diagnosis—are there diagnoses that are noted as rule out, probable, possible, cannot confirm, etc.?

Make note of those diagnoses so that you can follow the progression of each diagnosis as the patient receives inpatient care. You don’t want a diagnosis to drop off without resolution. Ensure that there is enough clinical information in the chart at this point to support the diagnoses the physician chose. With an understanding of how principal diagnosis is determined, what do you think the principal diagnosis is at this (albeit early) point? Also identify any early, potentially relevant secondary diagnoses. If the H&P is missing, make yourself a note to keep looking for it. If consults have been ordered, or you are expecting a consult to be ordered, make a note to look for the reports. Do you see a clinical picture without a diagnosis that might require a query?

Tip: Remember that when the chart is coded, the H&P and the discharge summary are going to carry the most weight.

Step 3: Look at vital signs and intake and output (I&O). Vital signs can give a strong clue in many cases as to just how sick your patient might be. You definitely need to note abnormals. I&O can help you if you’re looking for signs of acute renal failure due to dehydration, for instance. Determine if there are there any clinical conditions you might associate with the abnormal vital signs, such as a post-operative fever. Do you have enough supporting documentation to ask the physician if he or she suspects clinically significant atelectasis? Remember that when you evaluate for sepsis, fever is one of your SIRS indicators.

Step 4: Review labs and radiology reports. If there are abnormal findings, consider the clinical significance of those findings for the patient’s care. If the physician hasn’t addressed the abnormal findings in his or her documentation, make a note of those findings and follow the patient’s progression in future tests. As a CDI specialist, you may note a clinical progression based on those test results. Coders cannot code directly from labs or radiology reports, so if there is evidence of something clinically significant to report, query the physician. For instance, a patient with documentation of a subdural hematoma, mental status changes, and a decrease in their Glasgow coma scale may have had a brain MRI indicating mass effect and a midline shift. In this case you would probably query the physician regarding possible brain compression.

Step 5: Review any procedures that may have been performed. Of course you will review operative notes, but be aware that procedures can be sneaked into physician progress notes, such as a bedside debridement. Note who performed the procedure because you’ll need to direct any questions about that documentation to the physician who performed it, not necessarily the attending physician.

Step 6: Review any consult notes or dictations. If the consulting physician’s diagnosis significantly contradicts the attending physician’s diagnosis, you probably need to query. Be very cautious about taking a diagnosis written by a consultant that is outside their usual scope of practice, if it is not confirmed by the attending (e.g., acute respiratory failure written by a podiatrist). What you hope to see is clarification of the attending physician’s initial finding or suspicion with greater detail from the consultant. If the attending has written CHF, but the cardiologist writes acute systolic heart failure, pick up that improved diagnosis; no query is necessary.

Step 7: Review documentation from other disciplines. Look for nursing or dietary documentation of the patient’s body mass index (BMI). When combined with a related physician diagnosis, BMI less than 19 or greater than 40 can be a coded condition. Look at the dietitian notes to see if there is evidence to support a query for malnutrition. Look at nursing documentation to support present on admission (POA) documentation, of hospital-acquired conditions, or patient safety indicators. Verify that there is no documentation from other disciplines that radically contradicts physician documentation.

Step 8: Assign working codes for your principal and secondary diagnoses. Consider a possible DRG, but do not worry too much about getting the DRG correct. Focus on the principal diagnosis, the chief secondary diagnoses, and the principal procedure. Regardless of whether you work in an environment where you are responsible for the DRG assignment, you do need a working knowledge of MS-DRGs, ICD-9, and, beginning in 2013, ICD-10.

Step 9: Look at that chart again tomorrow. If you wait, your patient may be discharged. When you follow up on cases:

1. Look for any documentation expected after your previous review. Review it as you did for the initial review.
2. Look at lab trends. Consider the patient presentation you would expect with the lab trends (i.e., patient getting better or worse). Is there evidence of a clinical condition that is not being documented appropriately? See if the vital signs have changed.
3. Review any new documentation. Examine the progress notes. If there are any new consults, determine their effect on the principal and secondary diagnoses. Determine if any new procedures were performed and review new radiology reports. Now you are looking at continuity. Are the diagnoses you saw on the last review still there? If not, where did they go? If the diagnosis dropped off the chart and you suspect in your clinical judgment that it was probably valid, you might query the physician to ask about the status of the diagnosis.
   If the diagnosis was only stated as “possible” or similar term of uncertainty and now it is not mentioned, you might query to verify that the diagnosis was ruled out. For example, if the physician documented encephalopathy yesterday but wrote delirium today, you may want to query to ask if the original diagnosis of encephalopathy is still valid and if it has clinically progressed to the diagnosis of delirium or if the encephalopathy diagnosis was ruled out and was replaced by a diagnosis of delirium. When you look at the clinical picture, do you see diagnoses that could be present but aren’t in the documentation? Check the medical record to see if the physician documented symptoms without a diagnosis. Query your physician to document at least what they are ruling out as the underlying cause of the patient’s symptoms.
4. Re-evaluate your assessment of the principal diagnosis, secondary diagnoses, and principal procedure with each review. It often changes radically between admission and discharge. Remember that the principal diagnosis is the reason for admission determined after careful study, not necessarily what the admitting physician thought at the time of admission.
5. Plan to look at that patient again tomorrow.

Step 10: Follow through to discharge. Determine if the discharge summary follows, in logical progression, the flow you’ve seen in the chart thus far. Watch for diagnoses that come out of left field. Remember that the discharge summary carries the most weight when a chart is audited, so it’s really critical for the case to be wrapped up nicely at the end. Unfortunately, we often see is physician documentation of the condition of the patient at the time of discharge without consideration for the progression over time, or a very hurried, short summary. Sometimes diagnoses never mentioned during the stay show up in the discharge summary.

Look back through the medical record and through your own notes to make sure there is support for those diagnoses. While it is not mandatory for diagnoses to be mentioned throughout the chart, auditors look very skeptically on diagnoses that don’t seem to connect to previous documentation of the patient’s hospital course. Take a last look at all the unconfirmed diagnoses you have been following, because if they weren’t confirmed prior to discharge, or not mentioned at the time of discharge as still being possible, coders can’t code them. If you want to capture that diagnosis, you will need to query.

Often you will not have the discharge summary when you are closing out a record. You have to realize that everything might change in a month when that dictation comes through. It’s also challenging when you have a very confusing chart and you’re hoping the discharge summary will tie up the loose ends. Do the best you can with it. Let the coder know if you have any outstanding queries on your discharged patient. Talk to your coder about how they see the final chart coding out, come to an agreement about DRG assignment, and determine if any retrospective queries will be necessary.

Everyone has a unique review style, but sometimes it helps to break it down into the small parts. Does your CDI process mirror mine? What’s your style?

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.