Documentation Assessment Service

RWHC has partnered with Clear Medical Solutions and experienced physicians to offer a comprehensive service to assess hospital documentation. Our team will conduct a real time, on-site review of your workflows, procedures, coding, and documentation.

The review will include an overall analysis of hospital clinical documentation functions. Chart reviews will focus on Emergency Department (ED) encounters, where the majority of your patients initially access care. We will focus on high risk and complicated cases to strengthen documentation practices, core measure data outcomes, and accurate coding.

Reviewers will work in harmony – using their individual expertise – to assess four essential documentation components:

  1. Clinical Documentation Functions (Jane Duerst Reid, Clear Medical Solutions) – An overall baseline evaluation will assess current processes, medical staff bylaws, and policies & procedures in regard to state and federal regulations.

  2. Hospital Core Measure Data(Beth Dibbert, RWHC) – Chart reviews of twenty high risk diagnosis-specific ED records will assess your current documentation content and workflow. The assessment will focus on the assignment of the working diagnosis coding for core measures inpatient and outpatient population inclusion, capacity for concurrent quality data abstraction, and recommendations for a seamless transition to the ICD-10 environment.

  3. Accurate Coding Functions (Sheila Goethel, RWHC) – Chart reviews of twenty diagnosis-specific ER encounters will assess accurate coding functions and ICD-10 documentation expectations. The assessment will focus on accurate ICD and CPT code assignments, legibility checks, modifier assignments, and a documentation impact analysis for ICD-10.

  4. Peer Review of Physician Documentation (Practicing Rural ED Physicians) – Six ED records will be reviewed offsite by an independent ED physician to provide an unbiased report of the provider’s clinical content, HPI, and physical exam documentation, appropriate use of ancillary tests, and elements of admitting orders or discharge instructions.

Call us today or click here for more details about this unique, tailored service that will help you take the first steps to successful documentation improvement.

Contact Sheila Goethel for more information at 608-643-2343 or sgoethel@rwhc.com.

 

 

 

Document Assessment Service - Details

Clinical Documentation Functions – This first component will be conducted by Jane Duerst-Reid, RHIA, HIM Consultant, Clear Medical Solutions. Jane will provide an overall baseline evaluation of clinical documentation functions. This review will assess current processes, medical staff bylaws, policies & procedures in regard to state and federal regulations pertaining to the following:

  • Coding Practices and Functions

    • Coding and Abstraction

    • Coding Query Process

    • Coding Compliance Plan

    • Review of internal and External Coding Audits

    • Monitoring for Accuracy and Completeness

    • Productivity Monitoring

    • Staffing and Job Description Review

  • Documentation Practices

    • Medical Record Completions Requirements

    • Review of the Content of the Medical Reports

    •  Delinquent Medical Record Processing

  • Dictation/Text Entry Practices

    • Quality of Dictation/Text Entry

    • Timeliness of Dictation/Text Entry

    • Issues with Dictation/Text Entry

  • Transcription functions

    • Turnaround Time by Report

    • Templates and Macro Usage

    • Monitoring for Accuracy

    • Productivity Monitoring

    • Staffing and Job Description Review 

Hospital Core Measure Data – A second component will be provided by Beth Dibbert, CPHQ, Quality Consultant, RWHC. Beth will conduct a chart review of twenty ED records, diagnosis specific, to examine your core measure data. This review will assess core measure populations and documentation to identify the unique populations as follows:

 

  • Acute MI and Chest Pain

    • Aspirin at Arrival

    • ECG and Transfer Timing

    • Eligibility for Fibrinolytic Therapy

    • Troponin Results Timing

  • Stroke

    • CT Scan or MRI Utilization and Results Timing

  • Pain Management Timing for Long Bone Fractures

Using documentation for general ED core measure populations:

  •  Door to Diagnostic Evaluation Timing

  • Transition Record Elements

  • ED Throughput Timing

  • Patients Who Left Without Being Seen

In addition to the Core Measure population, Beth will also review the current workflow and efficiencies to include:

  •  Assignment of working/preliminary diagnosis code as driver of:

    • Clinical Decision Making

    • Care Pathways

    • Patient Admission/Transfer Status

Accurate Coding Functions – The third component will be conducted by Sheila Goethel, RHIT, CCS, Coding Consultant, RWHC. Sheila will review twenty ED encounters and focus on accurate ICD and CPT coding functions, as well as a documentation review for ICD-10 expectations. This review will assess coding functions as follows:

  •  Legibility Checks

    •   Review physician legibility issues

  • ICD-9/CPT Coding Accuracy
    • Review ICD Diagnoses Codes for Appropriate First Listed Code and Accuracy of All Secondary Codes
       
    • Review CPT Procedure Codes for Accuracy (excluding infusion/injection CPT)
       
    • Validate Physician EM
       
  •  Modifier Accuracy

  • Documentation Availabilities and Expectations that will be Required Under ICD-10
    • Documentation Review Specific to Chief Complaint
       
  • Provide Details of Documentation Expectations that will be Required Under ICD-10 for the Diagnoses included Within the Review

Peer Review of Physician Documentation – A fourth component (optional) will be provided by a practicing, ER/FP board-certified ED physician. The physician will review six cases chosen by RWHC staff. A qualitative analysis will be performed checking for:

  • Documentation Content, Clinically Pertinent for Chief Complaint and ROS

  • Critical Elements that would Justify Ordered Ancillary Services

  • Adequate and Suitable Admitting Orders or Discharge Instructions

  • Quality of Content for Receiving Provider and/or Subsequent Health Care Needs

Summary Report

The Documentation Assessment Service will identify the documentation opportunities and/or root causes for ineffective processes. Hospitals will receive a Summary Report of all chosen components, providing an administrative report highlighting descriptions of findings, strengths, and recommendations. A teleconference will also be arranged with participating experts to discuss the summary report.

Pricing

Documentation Assessment Service-Four Components:  $8,600

Documentation Assessment Service-Three Components:  $6,600
(Does not include physician peer review)

For more information or to schedule your review, please send an email to sgoethel@rwhc.com.

 
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