Clinical documentation integrity in the time of COVID-19

May 4, 2020 / By Julie Salomon, BSN, RN

The healthcare landscape has changed drastically over the last few months. How should a Clinical Documentation Specialist (CDS) carry on while physicians are on the battlefield fighting an invisible, unpredictable viral opponent, the SARS-CoV-2 coronavirus? For a CDS, this question and others are top of mind. Should clinical documentation programs slow down? How can a clinical documentation integrity team avoid burdening the physician further? What questions must be asked or avoided to limit disruption?

Accurate documentation has never been more important than in this time of COVID-19. Clinical documentation specialists are the keepers of the patient’s clinical story. Their collaborative partnership with physicians and coders ensures that patient data is complete. In a world without a CDS, significant diagnoses can be absent from the record or lacking in specificity, or coronavirus may not be captured at all. The impact of missing documentation will surface in rapidly declining severity of illness (SOI) and expected risk of mortality (ROM) scores in hospital populations. The data used for assessing COVID-19 patients for future reimbursement, SOI and ROM will be skewed reflecting less complexity. Additionally, national benchmarking and research data will be inaccurate without the rigor of clarification provided by clinical documentation integrity teams.

The clinical documentation specialist’s role has also changed. Gone are the days of straightforward case reviews. In the past, a CDS had clear expectations of what needed further investigation, based on a patient’s presenting body system diagnoses. Although the CDS continues to be the frontline investigator, searching for the connections in the words recorded or missing in the documentation, the difference now is that there are so many unknowns. What are the clues that may be critically important now or the key to unlocking COVID-19 connections later? Coronavirus touches every organ system, making the job of the CDS quite complicated. In many cases, patients present without any evident connection to COVID-19  and only later the diagnosis becomes clear or suspect.  

The respiratory component of COVID-19 is the earliest presentation with initial symptoms of fever, dry cough, dyspnea and ground glass opacities on chest X-ray. The most alarming initial development is patients who begin to recover, then take a turn for the worse and develop acute respiratory distress syndrome (ARDS), cytokine storm and potential death. This is the expected patient presentation with an obvious link to COVID-19. In this case, the focus is on fully capturing the comorbid diagnoses and organ system involvement. While it may sound like an easy task, physicians in hospitals at the epicenter of the pandemic are facing unprecedented patient volumes. Clinical documentation specialists must adapt by triaging documentation clarifications, limiting queries to the most critical situations.

Recent published studies and physician accounts illustrate the rapid evolution in understanding of the virus. After careful study, seemingly unrelated cases are found to be the coronavirus attacking organ systems in unexpected ways. Every patient seen must be treated as suspect. For example, a 30-year-old healthy male presenting with a large vessel stroke, asymptomatic for COVID-19 but later testing positive. The 12-year-old healthy girl with a stomachache who goes into cardiac arrest and requires a life flight, later found to be COVID-19 positive.  Patient presentation can cloud the  present on admission (POA) status of COVID-19 raising the question of what should be considered POA versus hospital acquired COVID-19 with potential risk. Going back to clinical documentation integrity basics is critical in establishing what is present on admission versus what is discovered after careful study.

Along with the importance of POA and careful study, the links and relationships of all diagnoses must be crystal clear. Comorbidities such as cardiovascular disease, cancer, kidney disease, chronic lung disease, obesity and hypertension become key predictors and definers of mortality risk. In addition, as the coronavirus directly targets organs and ignites the immune response, organ systems spiral out of control resulting in pulmonary embolism, sepsis, stroke, cardiac arrest, clotting and acute kidney failure. The loss of acuity, specificity or diagnoses impacts the accuracy of individual patient stories and taints future data as well.  

How can the clinical documentation specialist triage accordingly? Leveraging technology can lighten the load by helping the CDS focus on value cases. Utilizing prioritization and auto populating worklists specific to COVID-19 allows targeting of both the confirmed coronavirus cases and suspected cases as well. The list of symptoms has grown to include headache, abdominal pain, thrombosis, diarrhea, nausea, and vomiting, all of which can be utilized to uncover suspected unconfirmed patients. Prioritization can illuminate high-value patterns in case presentation so the most important clarifications can be acted on prior to discharge. 

So, can the data wait? Should the CDS step back from the physician? Or should the CDS be the partner the physician needs now to assist with recording the true story of this battle? In the absence of accurate documentation, data is lost, resulting in mistaken hypotheses. It will take some time to learn all the twists and turns of COVID-19’s sinister patterns. A rich data set will provide the knowledge and clinical connections needed, and provide the experts with meaningful insights to win the next battle and ultimately the war.

Julie Salomon is a 360 Encompass Chief Product Owner at 3M Health Information Systems.

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During a pandemic, healthcare information is gathered, studied, and published rapidly by scientists, epidemiologists and public health experts without the usual processes of review. Our understanding is rapidly evolving and what we understand today will change over time. Definitive studies will be published long after the fact. 3M Inside Angle bloggers share our thoughts and expertise based on currently available information.