The clinical content of a progress note should state in full a legible and understandable history. This should include a full assessment, including the positive and negative findings, interventions, and outcomes, as well as initial and ongoing assessments by each provider. Legible instructions should be included for all treatment therapies and medications. These records should be factual, consistent, and accurate.
When physicians disagree among themselves, criticism of that should not be on the record. In fact, this variance should be documented in the chart and the provider making this decision should clearly document the processes that led to the decision.
It is unwise to include abbreviations. In cases where abbreviations are necessary, they should be spelled out fully the first time. Institutional policies should be followed for appropriate abbreviations. Jargon, meaningless phrases, irrelevant speculation, and offensive or subjective statements should not be written. Labels to describe a patient as obnoxious, belligerent, or rude can lead to serious allegations. In fact, direct quotes should be applied on the record. The patient’s refusal of treatment should be documented, including the patient’s stated reason for refusal, if provided, and any action taken by the provider, as well as patient education and notifying the patient and their family. Patients who refuse to accept treatment recommendations might bear partial responsibility for a subsequent injury, which is known as “contributory negligence.”
Vague terminology should be avoided (e.g. “Cl urine” could mean colored urine, clear urine, or cloudy urine) as it can be subject to interpretation. Institutional policies should be followed for reporting incident reports. Peer-review processes should be noted; however, do not indicate in the chart that an incident report has been filed or an event report has been completed. This can serve as a red flag and could give the plaintiff’s attorney the right to access the record.
Documentation red flags should be addressed on a daily basis. Progress notes should be catered not only to providing an accurate record of the physicians’ thought process, but as an assessment of the patient, keeping in mind that if this case is called into court three or four years later, the record will speak for itself.
Deepak Pahuja, MD, FACP,
hospitalist, director of CME,
Erie Physician Network Hospitalists,
St. Vincent Health Center, Erie, Pa.,
CEO, Aerolib Healthcare Solutions LLC;
Priyanka Chadha, MD,
cofounder, Aerolib Healthcare Solutions LLC
DRG Accuracy Increases Medicare Reimbursement, Reduces Risks
Clinical documentation integrity (CDI) programs started in the 1990s. Most of the programs were experimental pilots that assessed the impact on physician documentation and quality.
In 2007, the Centers for Medicare & Medicaid Services (CMS) implemented the Medicare Severity Diagnosis Related Group (DRG). The focus of the DRG system was severity of illness and mortality rates. Indicators such as present on admission (POA) and hospital-acquired condition (HCA) were added the next year to identify conditions noted when a patient was admitted into the hospital.
Currently, the purpose of the CDI program is to optimize the DRG by capturing conditions through clear, concise documentation and coding. Accuracy in reporting DRG assignments will increase Medicare reimbursement and reduce compliance risks. CDI program popularity has grown because of careful consideration of the benefits of implementation.
Are we ready for the change? Launching a CDI program is not an easy task. It takes courage, tenacity, patience, and a great plan. The success of a CDI program depends on one key element: buy-in by physicians at your facility. Yes, physicians. Physician resistance is high for two key reasons: time and education.