Clinical documentation improvement, or clinical documentation integrity, may be defined as a process by which clinical indicators, diagnoses, and procedures documented in the medical record are supported by the appropriate ICD-10-CM and ICD-10-PCS codes. Code assignments drive reporting for reimbursement, quality measures, hospital and physician profiles, regulatory requirements, and clinical data collection and research. In addition, documentation found within the hospital record is a key to communicating the patient's illness and care plan to providers managing the patient in the community. Therefore, the documentation that results in code assignment must be an accurate and complete representation of the severity of the patient's illness and the efficacy of the treatment plan. A well-constructed medical record will reflect an alignment of documented clinical indicators, associated diagnoses based on those indicators documented to the correct acuity and specificity, and procedures appropriate for the indicators and diagnoses.
Clinical documentation improvement specialists (CDISs) perform concurrent or retrospective reviews of the medical record, looking for conflicting, incomplete, or nonspecific provider documentation.1 When documentation requires greater clarity, the CDIS contacts the provider—the treating physician or advanced practice provider—with carefully constructed, specific questions, known as queries, designed to bring the documentation into alignment. In addition, the CDIS offers providers focused education on documentation principles to promote streamlined, precise documentation for future encounters.
Nurses should understand, just as providers must, that the CDIS is trained in very specific principles of documentation and reporting, and what may seem obvious to the clinician may not be obvious when the record is coded and reported because of carefully defined coding rules. For instance, heart failure with reduced ejection fraction, a well-understood clinical term, must be reported as unspecified heart failure unless the provider offers further documentation as to the acuity and whether it's systolic or diastolic in nature. The CDIS bridges that gap through education.
Although the vast majority of documentation that impacts ICD-10 coding comes from providers, nurses can have a significant impact on the medical record. Nurse managers should ensure that their team members have an understanding of nursing documentation's power. Nursing documentation adds tremendous value to the medical record. Providers see the patient in snapshot, but the nurse cares for the patient 24/7.
Nurses make a difference
One important contribution of nursing to the medical record is continuity. Sharp auditors will notice, and question, the validity of the medical record when nursing documentation is inconsistent with provider documentation. The responsibility for diagnoses rests with the providers, but their judgment can come under question if other disciplines documenting in the record offer conflicting information.
Nursing notes and assessments can be very helpful in supplying the basis for a provider query. Although atelectasis is a medical diagnosis that can only be made by a provider, nursing documentation of weak cough effort, poor performance on incentive spirometry, resistance to ambulation, diminished breath sounds on auscultation, or an unexpected temperature spike can lend support to the radiology report of atelectasis when the CDIS asks the provider about the diagnosis. Acute blood loss anemia is another commonly queried diagnosis. Accurately recorded postoperative drain or chest tube output, evidence of hemoptysis or hematemesis, or saturation of wound dressings, accompanying a drop in hemoglobin/hematocrit, can be used by the CDIS as indicators of blood loss when formulating a query.
Nursing documentation of the presence of an indwelling catheter, as well as an evaluation of urine quality and any urinary symptoms, in the admission assessment can be very useful when the CDIS asks the provider if a catheter-associated urinary tract infection (CAUTI) was present at the time of admission. In the same way, a nursing admission assessment documenting signs of infection at a vascular catheter insertion site may point the physician toward determining whether the catheter infection was present on admission. The present on admission status of certain diagnoses, such as CAUTI and stage III or IV pressure ulcers, as documented by the provider not only impacts the principal diagnosis—the reason for admission—but also defines when the diagnosis is reported as a hospital-acquired condition.
Mechanical ventilation duration is a critical element that must be reported, as well. It has been a target of not only recovery auditors looking to recoup money, but also of the Office of the Inspector General because it can have a significant impact on hospital reimbursement and has the potential for error and fraud. It may not always be clear from either provider or respiratory therapy documentation when the patient goes on and off the mechanical ventilator, especially when there are extended weaning trials. ICU nurses who are diligent in documenting the time of intubation and extubation, as well as the use of any T-pieces for tracheostomy patients, can greatly assist in the accurate reporting of mechanical ventilator hours.
Another diagnosis that's important but less well known is functional quadriplegia. A patient with functional quadriplegia has a condition, such as dementia, severe contractures, or arthritis, which severely limits mobility. The patient may lack the cognitive function required for mobility. Very often there's advanced neurologic degeneration that isn't associated with a neurologic or traumatic injury. The patient has the same functional capacity as someone who has been paralyzed through spinal cord injury. Nursing documentation that helps the CDIS consider functional quadriplegia includes pressure ulcers and other skin breakdown, flexion contractures, urinary and fecal incontinence, and total care with activities of daily living. The Braden Scale for Predicting Pressure Sore Risk will reflect a bedfast patient with complete immobility. This nursing documentation can lend powerful support to a CDIS provider query.
Some diagnoses can be reported specifically from nursing documentation. If the provider has documented the presence of a pressure ulcer, the stage, as documented by nursing, can be reported. Therefore, accurate pressure ulcer staging is vitally important for precise reporting.
If the provider has documented a diagnosis such as obesity or morbid obesity, the body mass index, as documented by nursing, can be reported. One purpose of documentation and reporting of key diagnoses is accounting for resource utilization. Severely underweight and overweight patients often require a disproportionate amount of hospital resources. Heavier patients may need special equipment and additional nursing staff to meet their physical needs. Very underweight patients may have low functional reserves and intensified dietary requirements. Both of these patient populations can be expected to experience a longer healing process after surgery and a correspondingly longer hospital stay. Therefore, accurate recording of height and weight is critical.
Documentation and coding is a collaborative process that requires cooperation among all disciplines to create an accurate record of the patient. Thorough, compliant documentation not only ensures that hospitals have the resources they need to continue to care for their patients, but also promotes consistent, high-quality patient care through the healthcare continuum. Nursing must always be a part of this process.