Rosenbaum Benjamin P, Lorenz Robert R, Luther Ralph B, Knowles-Ward Lisa, Kelly Dianne L, Weil Robert J
Benjamin P. Rosenbaum, MD, is a neurosurgery resident at Cleveland Clinic in Cleveland, OH.
Robert R. Lorenz, MD, MBA, FACS, is an otolaryngologist and medical director of payment reform, risk, and contracting at Cleveland Clinic in Cleveland, OH.
Perspect Health Inf Manag. 2014 Jul 1;11(Summer):1c. eCollection 2014.
Documentation of the care delivered to hospitalized patients is a ubiquitous and important aspect of medical care. The majority of references to documentation and coding are based on the Centers for Medicare and Medicaid Services (CMS) Medicare Severity Diagnosis Related Group (MS-DRG) inpatient prospective payment system (IPPS). We educated the members of a clinical care team in a single department (neurosurgery) at our hospital. We measured subsequent documentation improvements in a simple, meaningful, and reproducible fashion. We created a new metric to measure documentation, termed the "normalized case mix index," that allows comparison of hospitalizations across multiple unrelated MS-DRG groups. Compared to one year earlier, the traditional case mix index, normalized case mix index, severity of illness, and risk of mortality increased one year after the educational intervention. We encourage other organizations to implement and systematically monitor documentation improvement efforts when attempting to determine the accuracy and quality of documentation achieved.
记录住院患者接受的护理情况是医疗护理中普遍存在且重要的一个方面。大多数关于记录和编码的参考依据是医疗保险和医疗补助服务中心（CMS）的医疗保险严重程度诊断相关组（MS-DRG）住院患者前瞻性支付系统（IPPS）。我们对我院单个科室（神经外科）的临床护理团队成员进行了培训。我们以一种简单、有意义且可重复的方式衡量了后续记录方面的改进情况。我们创建了一个新的衡量记录的指标，称为“标准化病例组合指数”，它能够对多个不相关的MS-DRG组中的住院情况进行比较。与一年前相比，在教育干预一年后，传统病例组合指数、标准化病例组合指数、疾病严重程度和死亡风险均有所增加。我们鼓励其他组织在试图确定所实现的记录准确性和质量时，实施并系统监测记录改进工作。
