Guest Post: The art of clinical documentation improvement

by Linda Renee Brown, RN, MA, CCDS, CCS, CDIP

I feel like saying a little bit about why we do what we do, or at least why I do what I do. In the course of my 26-year nursing career, I worked in many venues. For about 14 years, I was an ICU nurse, and although many patients have merged in my memory, there are those whose memory will always remain as fresh as yesterday. Somehow, I seem to remember everything about these chosen few, as if they had been painted in my mind.

I no longer provide direct patient care. In fact, these days I rarely see a patient in the flesh. Yet, every day I come to know anywhere from 40 to 90 individuals who come to the hospital in varying states of health. I know them through their charts. I know them because I am a clinical documentation specialist.

For me to do my job effectively, I must insure that the artists—the bedside caregivers—paint the most strikingly vivid picture possible of each and every one of these unique individuals.

When I read their charts, I visualize that patient in the bed. I see them complete with a face and a body. I see family members, monitors, tubes, medications. I see the physicians establishing—and sometimes struggling with—the big picture, and I see the nurses working as they provide hands-on care.

I read about the 32-year-old new mother with metastatic cancer and I feel her worry and her pain. I read about the noncompliant dialysis patient on his 10th admission for fluid overload and wonder what conditions could possibly lead to inpatient hospitalization being preferable to outpatient compliance. I read about the 90-year-old woman with a lump on her breast and I know she’s been agonizing over whether a mastectomy is worth it.

I see symptoms and I anticipate diagnoses. I see diagnoses and anticipate procedures. I see procedures and anticipate paths to recovery. Clinical documentation improvement is about making sure that the words match the reality. I need the physicians and nurses to write exactly what they see, what they think, and what they do. And I need them to say it in a way that satisfies government and managed care regulators.

Sometimes, I think of physician documentation in the context of the Blind Men and the Elephant. The Blind Men and the Elephant is an old tale from India in which six blind men each take hold of a different body part, unaware that they are touching an elephant. One man touches the tail and thinks it is a rope; another grasps the trunk and thinks it is a tree branch; a third thinks the tusk is a solid pipe, and so on. The reality is that they are all right and they are all wrong; it’s a matter of perspective.

As clinical documentation improvement specialists, we take the findings of the nephrologist and the cardiologist and the surgeon and the internist and we try to bring them together to understand the health concerns of the whole person so that everyone can recognize them. When we only see evidence of a tree branch or a rope instead of an elephant, we intervene.

When I was a nursing instructor, I used to tell my students that their path to becoming a nurse was not linearly following a series of tasks, but rather, slowly solving a complex jigsaw puzzle. Every new experience allowed them to add another piece, but the pieces might not be found in the order in which they looked for them. In time, though, one should eventually have a vision of the nurse taking shape, and fewer white spots on the table.

So it is with patients. A patient comes in with a vague complaint, and they expect the doctor to make a diagnosis. In the current status of healthcare’s revolving door, the physician has less and less time to make those determinations; determinations which nevertheless must be made. At times, a physician resists writing a possible diagnosis for fear of being wrong. I encourage doctors not to fear the diagnosis. A differential diagnosis, honestly considered, does not hurt either the patient or the physician. It merely shows the level of effort expended by the physician and the healthcare team in trying to solve the puzzle, and often that effort will be rewarded with greater severity of illness scores and perhaps even higher reimbursement.

I will help the physician understand how to write the diagnosis in a compliant manner that protects the patient, the physician, and the hospital.

The portrait has to be painted with some consistency. When one physician writes, “CHF,” while another writes, “pulmonary edema,” and a third writes, “fluid overload,” regarding the same set of symptoms experienced by the same patient, it’s the equivalent of three artists each trying to paint a perfectly pink dress with three different tubes of paint. One uses red paint, one uses white paint, and one uses orange paint. Without working together, none of them gets the color quite right. In the end, sometimes it isn’t even clear that the painting is of a woman in a dress, much less a woman wearing pink.

So, I help hand them the right paint, explain about the various rules of shading and perspective. In this metaphor I give them the right paint brush to use, offer up the appropriate words—acute systolic heart failure—and let them add it to their paintboxes. With the correct verbiage, everyone reading that chart, not only the regulators, sees the woman in her pink dress, sees the patient with acute systolic heart failure, and understands the diagnosis.

Nurses like to talk about the art and science of nursing. There is much science in the clinical documentation improvement role, but a lot of art, too.

Editor's note: Brown, at the time of the article's original response, was an independent CDI consultant based in Carrollton, GA. With experience in critical care, nursing education, disease management, case management, and long-term care, she has worked as a CDI specialist, educator, director, and consultant. She is a frequent writer on topics involving clinical documentation and published her own "The Case Manager's Quick Guide to Diagnostic Related Groups" in 2013.