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Improving Clinical Documentation in an Academic Setting: A Multidisciplinary Team Approach Focused on the Physician's
Deephak Swaminath1, Jennifer Hefner, Leigh Ann Jenkins
1clinical cardiac electrophysiology fellow, Yale-NewHaven Health, Yale School of Medicine, New Haven, Connecticut assistant professor, Department of Family Medicine, College of Medicine, The Ohio State University, Columbus, Ohio Cardiology Fellowship Program director, Texas Tech University Health Sciences Center Lubbock, Texas interventional cardiologist, Caprock Cardiovascular Center, Lubbock, Texas professor, internal medicine, Texas Tech University Health Sciences Center professor, The Ohio State University, Columbus.
Real-time clinical documentation specialist (CDS) feedback during physician rounds significantly boosts medical staff engagement and physician charges. This approach improves patient severity documentation, enhancing alignment between patient condition and medical records.
Area of Science:
- Healthcare Administration
- Medical Documentation
- Clinical Informatics
Background:
- Accurate patient severity and mortality prediction rely on high-quality clinical documentation.
- Current documentation improvement projects often lack real-time physician input and feedback loops.
Purpose of the Study:
- To evaluate the impact of real-time clinical document specialist (CDS) feedback on documentation quality and physician engagement.
- To compare a post hoc documentation review model with a real-time intervention model.
Main Methods:
- Pilot study at an academic medical center comparing two documentation projects.
- Control group: Attending physician-focused model with post hoc CDS review.
- Intervention group: Real-time CDS feedback during resident and attending physician rounds.
Main Results:
- Real-time CDS feedback led to increased medical staff participation.
- Significant increase in submitted physician charges observed in the intervention group.
- Documentation improvement projects align patient state with documentation but do not eliminate coding issues.
Conclusions:
- Real-time feedback from clinical document specialists is effective in enhancing documentation practices and physician engagement.
- Understanding the physician perspective is crucial for successful documentation improvement initiatives.
- Further research is needed to assess the broader impact of such programs beyond individual facilities.