Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
JAMA Otolaryngol Head Neck Surg. 2016 Jun 1;142(6):533-7. doi: 10.1001/jamaoto.2016.0194.
Physicians recognize the value of accurate documentation to facilitate patient care, communication, and the distribution of professional fees. However, the association between inpatient documentation, hospital billing, and quality metrics is less clear.
To identify areas of deficiency in inpatient documentation and to instruct health care professionals on how to improve the quality and accuracy of clinical records.
DESIGN, SETTING, AND PARTICIPANTS: A single-arm pre-post study was conducted from January 1, 2013, to December 31, 2014, among 17 attending and 12 resident physicians treating 1188 patients at an academic medical center. Data from 1 year prior to the intervention were compared with data for 10 months following the intervention. All increases were analyzed as a percentage increase after the intervention relative to before the intervention.
Areas for improvement were identified, and all physicians in the department received education on inpatient coding and documentation.
The capture rate for complications or comorbidities and major complications or comorbidities, the case mix index (the average diagnosis related group relative weight for a hospital or department), and severity of illness and risk of mortality scores.
A total of 1188 inpatients were included in the analysis: 743 in the preintervention period and 445 in the postintervention period. Review of our documentation identified major areas of comorbidity that were frequently underreported. Inadequate nutrition diagnoses (moderate malnutrition, severe protein-calorie malnutrition) were most often underreported. In addition, we found inadequate documentation supporting the presence of neck metastases. Among 1188 patients, the case mix index increased 5.3% (from 2.81 to 2.96) after the intervention, but this was not a statistically significant difference (P = .21). The normalized case mix index increased 21.7% (from 37.3 to 45.4; P < .01). The percentage of patients with a documented complication or comorbidity or major complication or comorbidity increased 27.1% (from 50.2% to 63.8%; P < .01). The percentage of patients assigned a severity of illness score of 3 or 4 increased 24.3% (from 34.7% to 43.0%; P < .01). The percentage of patients assigned a risk of mortality score of 3 or 4 increased 32.1% (from 18.7% to 24.7%; P = .01).
After educational sessions, multiple measures of patient acuity increased significantly owing to improved documentation of common comorbid conditions. Although physicians intuitively appreciate the importance of good documentation, education on the technical aspects of coding can significantly improve the quality and accuracy of clinical records.
医生认识到准确记录的价值，以方便患者护理、沟通和专业费用的分配。然而，住院患者记录、医院计费和质量指标之间的关联不太清楚。
确定住院患者记录中的不足之处，并指导医疗保健专业人员如何提高临床记录的质量和准确性。
设计、设置和参与者：一项单臂前后研究于 2013 年 1 月 1 日至 2014 年 12 月 31 日在一家学术医疗中心进行，17 名主治医生和 12 名住院医生治疗了 1188 名患者。干预前 1 年的数据与干预后 10 个月的数据进行了比较。所有增加的百分比均为干预后与干预前的相对增加。
确定了改进的领域，部门内所有医生都接受了住院编码和记录方面的教育。
并发症或合并症以及主要并发症或合并症的捕获率、病例组合指数（医院或部门的平均诊断相关组相对权重）以及严重程度和死亡率评分。
共纳入 1188 名住院患者进行分析：干预前 743 例，干预后 445 例。对我们的记录进行审查发现，经常报告不足的主要合并症领域。营养不足诊断（中度营养不良、严重蛋白质-热量营养不良）最常被漏报。此外，我们发现缺乏支持颈部转移存在的文件。在 1188 名患者中，病例组合指数增加了 5.3%（从 2.81 增加到 2.96），但这没有统计学意义（P = .21）。归一化病例组合指数增加了 21.7%（从 37.3 增加到 45.4；P < .01）。有记录并发症或合并症或主要并发症或合并症的患者比例增加了 27.1%（从 50.2%增加到 63.8%；P < .01）。被分配严重程度评分为 3 或 4 的患者比例增加了 24.3%（从 34.7%增加到 43.0%；P < .01）。被分配死亡率评分为 3 或 4 的患者比例增加了 32.1%（从 18.7%增加到 24.7%；P = .01）。
在教育课程之后，由于常见合并症记录的改善，多项患者严重程度指标显著增加。尽管医生凭直觉理解良好记录的重要性，但编码技术方面的教育可以显著提高临床记录的质量和准确性。
