Lost in translation: Focused documentation improvement benefits trauma surgeons
Lost in translation: Focused documentation improvement benefits trauma surgeons
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DOI：
10.1016/j.injury.2016.04.035
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发表时间：
2016-09-01
影响因子：
2.5
通讯作者：
Mazzarelli, Anthony J.
中科院分区：
文献类型：
--
作者：
Fox, Nicole;Swierczynski, Patricia;Mazzarelli, Anthony J.
简介：在记录病历的医生和编码人员之间存在翻译差距，编码人员最终决定提交哪些代码。这种差距之所以存在，是因为医生从未接受过关于文件策略的正式教育，尽管医生文件的质量直接影响到收入、结果和公众形象。我们评估了一种正式的聚焦文献改进模型（FDI）对创伤/重症监护室的影响。我们假设FDI将改善医生的记录，从而带来收入的恢复和病例组合指数（CMI）的转变，以更准确地反映创伤患者的临床复杂性。方法：FDI被定义为有针对性的医师教育，然后由临床文献专家（CDS）同时进行住院病历审查，以获得文献改进机会。我们一级创伤中心的所有创伤外科医生（n = 9）首先完成了三个小时关于文件改进的强制性培训。随后，一名CDS被分配到创伤服务部门。他们回顾了2014年1月至12月的医疗保险患者（n = 776）的图表，以确定文件改进的机会，参与ICU查房并提供持续的教育。澄清文件（查询）的请求张贴在电子病历（EMR）中，要求医生在48小时内作出答复。收集了医生回复率、CMI和收入回收率的数据。结果：776例病例中有411例（57%）被复查。在177个（43%）案例中发现了外国直接投资的机会。医生对询问的回复率为100%。回顾病例的CMI增加(1.80 (SD 0.15) vs. 2.11 (SD 0.19)；p < 0.001)。总体收入回收为1,132,581美元，平均收入回收为154,092美元/临床全职等效。管理外国直接投资的总费用为353,265美元，投资回报率为220%。结论：FDI是促使医生参与文件改进的有效策略。它提供了一个基础设施来帮助医生，并产生了显著的投资回报率。(C) 2016 Elsevier Ltd.版权所有。
Introduction: There is a translational gap between physicians who document in the medical record and coders, who ultimately determine which codes are submitted. This gap exists because physicians are never formally educated about documentation strategies despite the fact that the quality of physician documentation directly affects revenue, outcomes and public profiling. We evaluated the effect of a formal model of focused documentation improvement (FDI) on the trauma/critical care division. We hypothesized that FDI would improve physician documentation, resulting in revenue recovery and a shift in the case mix index (CMI) to more accurately reflect the clinical complexity of trauma patients.Methods: FDI is defined as targeted physician education followed by concurrent inpatient chart reviewfor documentation improvement opportunities by a clinical documentation specialist (CDS). All trauma surgeons (n = 9) at our Level 1 trauma center first completed three hours of mandatory training on documentation improvement. A CDS was subsequently assigned to the trauma service. They reviewed the charts of Medicare patients (n = 776) from January-December 2014 to identify opportunities for documentation improvement, participated in ICU rounds and provided ongoing education. Requests to clarify documentation (queries) were posted in the electronic medical record (EMR) and physicians were required to respond within 48 h. Data was collected on physician response rate, CMI and revenue recovery.Results: 411 of 776 (57%) charts were reviewed. Opportunities for FDI were identified in 177 (43%) cases. The physician response rate to queries was 100%. The CMI for reviewed cases increased (1.80 (SD 0.15) vs. 2.11 (SD 0.19); p < 0.001) after FDI. Overall revenue recovery was $1,132,581 with an average of $154,092 in revenue recovery/clinical full time equivalent. The total cost for administration of FDI was $353,265 resulting in a 220% return on investment (ROI).Conclusion: FDI is an effective strategy to engage physicians in documentation improvement. It provides an infrastructure to assist physicians and yields a significant ROI. (C) 2016 Elsevier Ltd. All rights reserved.