Improving Clinical Documentation in an Academic Setting

A Multidisciplinary Team Approach Focused on the Physician’s Perspective

Abstract

EXECUTIVE SUMMARY 

This research article discusses the results of a pilot study at a large academic medical center to appropriately describe patient severity and the likelihood of mortality. In this study, we compare two projects, both of which use a clinical document specialist (CDS). The control case measures documentation quality using an attending physician–focused model. This model, supplemented by a CDS who requests additional documentation on a post hoc basis, is measured against an intervention where a CDS offers suggestions in real time during rounds with residents and attending physicians.

Our findings indicate that documentation training with real-time feedback by a CDS results in higher levels of medical staff participation and a significant increase in submitted physician charges. Additionally, we note that documentation improvement projects do not eliminate coding problems; rather, they support a better alignment between patient state and documentation of that state. Although physicians are key players in the provision of care and the revenue cycle, the physician perspective is missing in the current discourse about documentation. Where quality, profitability, education, teamwork, and profiling drive documentation improvement, ensuring that we understand the problem from both ends is crucial to documentation improvement projects. Therefore, there is a need for more research on the impact of such programs beyond the facility.