Lack of physician engagement in clinical documentation improvement initiatives is not surprising for a variety of reasons. The main reason for this lack of physician engagement relates to the message being delivered to the physician as part of the clinical documentation improvement by the clinical documentation improvement specialists.

Clinical documentation improvement specialists (CDIS) are charged with reviewing inpatient records and identifying opportunities for clarifying additional diagnoses, whether they be potential principal diagnosis or secondary diagnoses referred to as CCs/MCCs. The clarification process entails constructing  a compliant written query for the physician to see and hopefully respond one way or another. Less frequently, verbal queries are used to elicit additional diagnostic information in the chart. CDIS often times wonder and agonize why physicians do not participate in the query process by responding to the queries. Therein lies the problem with CDI, the physicians should the medical record as a communication tool for good patient care and improvement in clinical outcomes

Engaging physicians in doing the right thing, that is adherence to sound practices of clinical documentation that accurately tells and retells the patient story in the name of good quality patient care, better outcomes, better coordination of care, utilization review/management and creation of value in the healthcare delivery model. Physicians are looking for assistance in creating a complete and accurate note reflective of the care provided and the physician work performed. They are looking for guidance in constructing a reasonable patient encounter note in the face of the time and construct challenges created by the often times constrictive electronic health record.

In many years of working with physicians in an effort to provide the necessary knowledge and appreciation of what constitutes an accurate and complete medical record, I offer the following information to share with physicians in an effort to provide a meaningful message of clinical documentation. If we can impress upon the physician the guiding principles of clinical documentation as follows:

Good documentation requires no change in the physician’s practice of medicine, just the reporting of the practice of medicine

  •  Focus upon capturing by documenting:
    • Where has the patient been
    • Where is the patient now
    • What are you thinking
    • Why you thinking
    • Where are you going and why
    • What did you find when you got there
    • What actions did you take, what actions are still needed and how long is it going to take
    • What actions remain for post-acute care

There is no time like the present to take the next step in engaging physicians in true clinical documentation through promotion of the value to the physician as well as the patient in a complete and accurate clinical documentation that effectively tells the patient story. Until clinical documentation improvement specialists update the message of clinical documentation improvement, there can be no real true physician engagement period.

By

Flavios Sonchos, MD