Close care documentation gaps — Expert tips for better quality reporting

Feb. 8, 2023 / By Jason Burke, Julie Salomon, BSN, RN

Health care has long been focused on delivering quality clinical care that results in positive patient outcomes. Unfortunately, clinical excellence is not always accurately captured in quality ratings and rankings if sufficient attention is not paid to documentation and coding. Patient outcome methodologies must consider both the clinical risk and severity of the patient when they enter and depart the hospital. Barring complications, patients that enter the hospital in overall good health expect to leave the hospital with positive outcomes. 

It requires greater context to understand whether a hospital performed well when a sick patient is discharged. Hospitals need a strategy to ensure providers, ancillary clinicians, clinical documentation integrity (CDI) and coding are working to fully document the patient story and doing so efficiently to minimize the impact on thinly staffed teams. The silver lining is that the same efforts required to accurately document quality also support the solid documentation needed for full reimbursement. Here are three things your organization can evaluate today as part of a robust quality plan and one trend to follow in the future. 

1. Visibility to quality metrics is often challenged by workflows that cross many different technology platforms. This type of technology ecosystem also makes it easier to have a multitude of measurement approaches and makes improving, and ultimately automating processes, much more challenging.  For instance, an organization with a heavy focus on financial impact may increase documentation of diagnoses capturing multiple chronic conditions such as acute respiratory failure or sepsis in a post-operative patient. This could increase payment substantially, however will also be a quality ding with a reduction in payment and penalty on the backend. If you find yourself in an organization with competing priorities and disparate technology systems, it is important to incorporate checks and balances. 

Get the full list of expert tips in the Becker’s Hospital Review article. 

Jason Burke is the vice president of revenue cycle solutions at 3M Health Information Systems. 

Julie Salomon, BSN, RN, is senior manager, revenue cycle strategy at 3M Health Information Systems.