Better case-note documentation can have a major impact on a hospital's budget under payment by results.
One very effective US programme involves case-mix awareness training for clinicians. They are shown examples of poor-quality documentation and then taught best-practice methods. One 3M study reviewed 450 coded casenotes at three US hospitals to measure the potential impact of poor documentation on how work was assigned to the US equivalent of healthcare resource groups.
Auditing to determine the impact of poor or incomplete notes found that the aggregate severity of illness (SoI) index would have increased by 5.8 per cent and the risk of mortality (RoM) index by 22.1 per cent. An estimated 9m would have been saved.
Areas in which clinical documentation can be poor includes:
Additional diagnoses correlating to treatment plans and diagnostic reports,
Required documentation of diagnoses,
Appropriate selection of alternative principal diagnosis.
Documentation of more specific diagnoses, which frequently result in improvement of SoI and RoM indexes. Training programmes for clinicians and coders should include skills to audit the case-note in depth; carry out or incorporate a coding audit; provide best-practice training for clinicians and coders; and monitor progress over a year.
Clinical documentation improves when coders use encoder software that identifies patients whose length of stay significantly exceeds that expected and then prompts them to query notes or clinicians for complications and co-morbidities that would explain the greater-thanaverage length of stay. Dialogue between coders and clinicians helps raise awareness that clinical documentation does impact case-mix HRG grouping, which is intended to reflect accurately the hospital's resource consumption. Even small things like making sure the most resource-intensive procedure is listed first among the procedures performed when submitted to central returns can have a significant impact on a budget.
A batch analysis of 346,274 coded finished consultant episodes (in full) from 10 acute trusts revealed the average trust could save 2m a year if complications and comorbidities are thoroughly documented and multiple procedures properly sequenced.
Homer Warner Jr is HIS business manager (Europe) for 3M Health Care