Improvement and Data Analytics
Combine to Improve Patient Safety
By Teresa Evers, RN, RHIA, CDIP, CCS
HEALTHCARE PROFESSIONALS HAVE all been subjected to
mountains of information urging them to amplify quality care
and patient safety. Everyone who works in healthcare, including health information management (HIM) professionals, must
strive to advocate and serve these two areas. Patient safety is an
evolving path connecting every member of the healthcare team.
The medical record is the chief communication tool used to
provide safe and efficient patient care and allow for appropriate
reimbursement of services and equipment.
This article will focus specifically on the link between the clinical documentation improvement (CDI) specialist and the data
analyst. The data analytics team must rely on the fact that the data
they review is an accurate reflection of the patient encounter.
Linking accurately coded data to pertinent clinical information
is the primary focus of most CDI teams. By working directly with
physicians and coders, CDI specialists help interpret, communicate, and educate the healthcare team to produce a clear and precise reflection of the care and progress of each patient encounter.
Precise Documentation Is a Must
The clinical staff within an organization are responsible for direct patient care and must document assessments, decision-making processes, and patient outcomes for translation of the
medical record into specified coded diagnoses and procedures.
Consistent and precise documentation in the medical record
produces favorable results and enhances information gathering
processes for analysis and process change. Data integrity is directly related to the input of information in the medical record
as well as the interpretation of the consolidated documentation.
Direct care providers record the essential foundation of docu-
mentation for data analysis. Provider communication with the
clinical documentation specialist team through queries and
education of coding guidelines and specificity requirements for
accurate coding produces favorable patient outcomes and fo-
cused data analysis of benchmarked data. 1
More than a keystroke, the information in the medical record
tells the story of the patient encounter. Quick access to positive
and negative outcomes is essential for healthcare providers when
determining the continuity of care and creating safe evaluation
and treatment modalities. Federal and state guidelines mandate
that physicians, and in some states nurse practitioners and physician assistants, have ultimate responsibility for accurate documentation and control over the content of the medical record. 2
CDI Team Vet Documentation for Care and Cost
The CDI team performs inpatient and outpatient reviews “to ensure that physicians provide the most complete, clear, reliable,
timely, legible, and precise documentation consistent with the
clinical findings in the medical record.” 3 CDI strives to combine
clinical and coding knowledge to substantiate correct DRG assignment and reporting of a secondary diagnosis. Concurrent reviews
help align patient information within the medical record for clarity and consistency, which facilitate coding accuracy. Additionally,
the CDI team communicates verbally or electronically with clinical
providers to educate them on the need for clear, concise, and specific documentation to facilitate proper coding for patient quality
and safety. Clinical validation may occur during the patient stay, or
retrospectively. CDI pulls data from a variety of entry points in the
medical record to confirm supporting documentation of a diagnosis. Monitoring for clinical validity within the medical record to
support the professional judgment of providers allows for further
study of patient safety and quality outcomes. 4