I was recently a participant at a conference for physician advisors, and one of the most interesting topics of discussion was the role of clinical documentation integrity in our ever changing medical landscape. The title of said discussion was something like, “Clinical Documentation Integrity: the Past, the Present, and the Future.” There were many ideas tossed around, but one of the major questions that caught my attention was, “What is the role for CDI in the emergency department?” I believe that this is a topic that is both interesting and timely. Therefore, we hope to use this blog as a venue to further this discussion, while attempting to keep the focus on the patient.
For many of our patients, the Emergency Department is the first point of contact the patient has with the health care system during their hospitalization. Accordingly, the Emergency Department, or ED is often called the front door of the hospital for this very reason. Therefore, quality documentation in the ED is essential and oftentimes the critical element necessary to demonstrate the medical necessity of the patient remaining in the hospital or returning home. We all understand that, as the name implies, the Emergency Department, is a setting where things can move at dizzying pace. Time is of the essence, and lives are often at stake. However, even in the often-hurried pace of care in the Emergency Department, effectiveness and completeness of medical record documentation is critical for a wide variety of reasons. First and foremost, the medical record serves as communication tool for all care provisions and healthcare stakeholders including the patient. The medical record also serves other purposes including a communication tool accounting for the patient care provided, medical-legal, documentation for charge capture, quality of care and outcomes measures, measures of efficiency and effectiveness and coding and billing. Inherent in the communication of patient care is the establishment of medical necessity for not only care provided, but, equally as important, for the decision to treat and discharge or recommend hospitalization.
The recommendation to the attending physician can be either observation or inpatient level of care. This decision is of great financial importance to our patients, particularly those with Medicare as their primary payer source. The difference between being hospitalized with observation services, versus being hospitalized for an inpatient admission, may mean thousands of dollars in out-of-pocket expenses for our patients, as a result of distinct differences in payment from Medicare Part A and Part B. The clinical documentation in the Emergency Department is vital in providing, reflecting and reporting the patient’s presentation to the hospital in detail, and this point cannot be overemphasized. So in our next few posts, we will discuss the components of effective ED documentation that will help depict the severity of illness of the patient, thus establishing the medical necessity of the patient remaining in the hospital or being treated in a more appropriate, less intense setting.