Note from the Speaker: What’s the big deal with only documenting symptoms and treatments?

By Sandra Love, RN, BSN, CCDS, and Melinda Matthews, RN, BSN, CCDS, CDIP

We all know that numerous barriers keep physicians from embracing CDI efforts fully. In our presentation, “Little Kids, Big Doc? Big Problem: Meeting the Challenges of Pediatric Physician Engagement,” we discuss key solutions to overcome such barriers successfully.

For example, we answer common physician questions such as:

• Was the patient record created for billing?
• What are the important uses of the patient record?
• Is the record a communication tool to document the care provided amongst the treatment team or is it a billing tool?
• Certainly, safe continuity of care should be the priority. Have we, in healthcare, lost our focus?

Brenner Children’s Hospital is a 144-bed “hospital within a hospital” affiliated with Wake Forest Baptist Health in Winston-Salem, North Carolina. As an academic medical center, we train our students and resident physicians to recognize, analyze, and capture the signs/symptoms demonstrated by the patient. This problem-based approach to medicine does not always translate into the medical terminology (diagnoses) needed for correct and complete final coding. What seems to be lost in the translation is how these new physicians use their words.

Often, physicians and residents ask why they have to include a particular diagnosis when their documentation includes the symptoms observed and the treatment provided. A great example is malnutrition. The provider will document the z-score of 2.89, the current weight, symptoms such as excessive fluid loss from diarrhea and malabsorption related to celiac disease; however, they do not understand the need to document the diagnosis of malnutrition. Generally, our response is something like “understandably, the requests we send can be tedious and time consuming. Please know, our goal is accurate, complete, and compliant documentation to ensure continuity of safe patient care.”

To further help the residents understand this concept, the CDI team provides education regarding the need for the accurate medical diagnoses treated to support medical necessity for the hospital stay, the severity of illness treated, and the likelihood of death if treatment had not been provided.

To assist us with this process, we partnered with various departmental leaders, including the associate chief medical officers, the chief of pulmonary critical care medicine, hematology, and nephrology to create a clinical indicators policy/procedure. This formalized policy is applied across the enterprise as an assistive tool for both our staff and the physicians when translating symptoms into actual medical diagnoses. As a tool it assists with capture of medical diagnoses and the appropriate clinical indicators to support final coding.

Editor’s note: Matthews and Love will be presenting during the first breakout session on Day 1 of the conference in the pediatric track. The title of their presentation is “Little Kids, Big Doc? Big Problem: Meeting the Challenges of Pediatric Physician Engagement.”