All authors: Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA.
Crit Care Med. 2020 Apr;48(4):579-587. doi: 10.1097/CCM.0000000000004200.
The aim of this review is to describe the interaction of clinical documentation with patient care, measures of patient acuity, quality metrics, research database accuracy, and healthcare reimbursement in order to highlight potential areas of improvement for intensivists.
An online search of PubMed was undertaken as well as review of resources published by the American Academy of Pediatrics, the Society of Critical Care Medicine, the American Medical Association, and the Association of Clinical Documentation Improvement Specialists.
Selected publications included those that described coding, medical record documentation, healthcare reimbursement, quality metrics, administrative databases, Clinical Documentation Improvement programs, medical scribe programs, and various payment models.
Relevant information was extracted to highlight the impact of diagnosis documentation on patient care, perceived patient severity of illness, quality metrics, and healthcare reimbursement. Query data from our hospital's Clinical Documentation Improvement program were reviewed to highlight areas of improvement within our own Division of Critical Care Medicine. Additionally, interventions to improve clinical documentation were incorporated into this review.
Available data in the literature indicate that documentation of precise diagnoses in the medical record has a positive impact on quality metrics, accuracy of administrative databases, hospital reimbursement, and perceived patient complexity. However, there is insufficient data to make conclusions regarding documentation of specific diagnoses and effects on patient care. Administrative responsibilities associated with documentation have been increasing, especially with the introduction of electronic medical records.
Documentation of specific diagnoses in the medical record is important in the broad context of our existing medical system but there is an associated burden in doing so. Widespread implementation of electronic medical record systems has inadvertently led to clinician dissatisfaction and burnout. Research is needed to further evaluate the impact of documentation on patient care as well as steps to decrease the associated burden.
本综述旨在描述临床文档与患者护理、患者病情严重程度测量、质量指标、研究数据库准确性和医疗保健报销之间的相互作用，以突出重症监护医生潜在的改进领域。
通过在线搜索 PubMed，并回顾美国儿科学会、危重病医学会、美国医学协会和临床文档改进专家协会发布的资源，进行了资料搜索。
选定的出版物包括那些描述编码、病历文档、医疗保健报销、质量指标、行政数据库、临床文档改进计划、医疗记录员计划和各种支付模式的出版物。
提取了相关信息，以突出诊断文档对患者护理、感知患者病情严重程度、质量指标和医疗保健报销的影响。我们医院的临床文档改进计划的查询数据被审查，以突出我们重症医学科内部的改进领域。此外，还将改善临床文档的干预措施纳入本综述。
文献中的现有数据表明，病历中精确诊断的记录对质量指标、行政数据库的准确性、医院报销和感知患者复杂性有积极影响。然而，没有足够的数据来得出关于特定诊断的记录及其对患者护理的影响的结论。与文档相关的行政职责一直在增加，尤其是随着电子病历的引入。
在我们现有的医疗体系中，病历中特定诊断的记录在广泛的背景下很重要，但这样做也有相关的负担。电子病历系统的广泛实施无意中导致了临床医生的不满和倦怠。需要进一步评估文档对患者护理的影响以及减轻相关负担的措施。
