Teaching clinical documentation to fellow physicians
Clinical documentation may not be the most exciting topic, but changes to the healthcare landscape are bringing further attention to its importance. Without proper documentation training, physicians can put their patients and facility at risk, as well as negatively impact their facility's bottom line. Despite this, clinical documentation training can often be overlooked.
Finding a lack of resources and tools that provide direction on clinical documentation for physicians, Joseph Cristiano, MD, assistant professor of general internal medicine at Wake Forest Baptist Health in Winston-Salem, North Carolina, set out to educate himself about the topic. During the process, he found that many seasoned colleagues were equally in the dark in regard to clinical documentation. Recognizing this as a learning opportunity, Cristiano began informally educating himself by reaching out to the business and compliance offices at Wake Forest, which led to other individuals within his institution with clinical documentation experience. Eventually, finding he had a good grasp on evaluation and management billing and office visit billing, he started teaching faculty throughout the institution. He did so in collaboration with the compliance office.
"One of the things I realized, as I worked closely with our compliance and audit departments, is that there's a lot of area for improvement, particularly in resident clinical documentation," says Cristiano.
The rise of electronic medical record (EMR) systems has led to increased transparency. With EMRs that are now compliant with CMS' meaningful use incentive program, there is a greater interconnectedness of patient information that allows regulatory agencies, reporting agencies, auditors, and payers access to medical records. "I tell students and residents that in the past the only people reading their notes were their colleagues who were treating a patient alongside them. Now there's a whole other audience of folks reading them and looking specifically for elements of clinical documentation," Cristiano says.
Increasing accountability in medicine has also brought more attention to the importance of clinical documentation as medical errors are publicly reportable and certain kinds of errors, such as hospital-acquired conditions, are required to be reported to CMS, he says. "If [physicians] don't accurately document that something like a decubitus pressure ulcer was present on admission, then by default it would be considered a hospital-acquired condition. That would have to be reported to CMS and would affect the [physician's and the hospital's] quality metrics."
Source: Medical Staff Briefing