Download History of Present Illness

Clinical Documentation
Improvement (CDI)
Physician Documentation
This module will provide you with key
strategies for meeting both professional
and hospital documentation
requirements because hospital
reimbursement and quality metrics are
dependent upon physician
documentation
History & Physical
• Chief Complaint
– Be clear about which complaint (if there are
multiple) is the reason for inpatient hospitalization
• Chronic conditions don’t usually require hospitalization
unless the condition is exacerbated
– Document the risk associated with not treating
the chief complaint in the inpatient hospital
setting
• Concern for specific complications/adverse outcome
• The likelihood of an adverse outcome if not treated in
the inpatient setting
History & Physical
• History of Present Illness
– Includes all the clinically relevant elements related
to the chief complaint (why the patient is seeking/
requires inpatient medical care) and includes the
information on the following slides:
History of Present Illness
• Duration
– How long has the patient had the chief complaint?
• Be as specific as possible e.g., onset within last 24 hours,
onset within last week, exacerbated chronic condition, etc.
• Severity
– Is this a “typical” or “chronic” presentation or is the
chief complaint a new concern?
• Be sure to note how the patient's condition differs from
baseline if this an exacerbation of a chronic condition
• Be sure to highlight any “acute” or new sysmptoms
History of Present Illness
• Associated Signs & Symptoms
– Explain the probability of an adverse outcome
without immediate treatment or intervention
– Differentiate new conditions from chronic
illnesses; note when outpatient treatment failed
and when the condition poses a threat to life or
bodily function
• Clearly specify which are new complaints requiring
workup and include the term “acute”
• Document your suspected etiology stating “evidence of
. . .” requiring further workup
History of Present Illness
• Always note an abrupt change in
neurological status
• For existing conditions that are not chronic,
state if the condition is resolved or if
treatment continues
– “Treated at outside hospital (OSH) for pneumonia;
will continue to monitor and treat”
– “Treated at OSH for pneumonia; appears
resolved”
History of Present Illness
• Chronic conditions
– Include all relevant co-morbidities/
diagnosis that contribute to the complexity
or severity of the case clearly noting
• A severe exacerbation of a chronic condition
• Progression of a chronic condition
• Side effects of treatment for a chronic condition
History of Present Illness
• Some chronic conditions have associated
diagnoses that require more detail:
– Consider “chronic respiratory failure” if on home
oxygen, CPAP or BIPAP with COPD or obstructive
sleep apnea
– Consider “obesity hypoventilation syndrome” for
the morbidly obese
– List all behavioral disturbances for a patient with
dementia, noting the type if known
– Specify the type of heart failure as systolic (more
common) or diastolic, or both
History of Present Illness
• Always note when the patient has failed to
follow his/her treatment plan, e.g., missed
follow up appointments, non-compliance with
medications, etc.
– The valve of this information will increase with the
CMS Quality Measure of readmissions as it is
important to demonstrate when a readmission
was unavoidable due to a lack of patient
compliance with the treatment plan
Review of Systems (ROS)
• If you suspect morbid obesity or
malnourishment always note it and document
how this condition complicates or exacerbates
treatment
– You may want to order nutritional consult which
will provide a BMI to support the diagnosis;
however, you must document the BMI
• Include the observations of cachexia/cachetic
or emaciated when applicable for general
appearance
Past Medical, Family & Social History
• Address the immunization status of pneumonia
and flu vaccines
– Start asking the status of flu vaccination in
September as Quality Measures are based on
discharge dates so a patient can be admitted prior
to flu season but discharged during flu season
• If excessive alcohol use requires treatment with
vitamins/banana bag, consider documenting
“evidence of thiamine deficiency”
Past Medical, Family & Social History
• Consider the diagnosis of “narcotic dependence”
(which isn’t the same as abuse) for any patient
who has long term use of narcotics or other
prescribed substances that lead to a
physiological response if abruptly discontinued
– Note any withdrawal symptoms
– Specify the type of narcotic
– This diagnosis should always be considered on any
patient requiring evaluation by the pain
management team
Daily Progress Notes
• Documentation of medical decision making
should occur daily, so each note should
contain
– Current condition of the patient
• “Remains unstable,” “remains exacerbated,”
progression of symptoms, “stable with continued
concern for . . .”
• Daily documentation must support the continued need
for hospitalization
– Adults who are stable for ≥ 12 hours should be
transitioning to the next level of care
Daily Progress Notes
• State all diagnoses being evaluated or treated
each day
– Consider use of a problem list allowing for daily
documentation of the status of the condition
– Note when a suspected diagnosis has been ruled
out AND when a diagnosis/complaint has been
resolved
– Link the chief complaint and its etiology to the
symptoms that were present on admission (POA)
especially when the etiology is not identified until
several days within the admission e.g., sepsis,
pneumonia
Daily Progress Note
• Always document the onset of new conditions
that occur during hospitalization as “acute”
– Be sure to provide documentation and an
associated diagnosis for any phone orders
• Note when you have reviewed and/or
discussed diagnostic tests with the performing
or interpreting physician
– “Reviewed radiologist findings and agree”
Discharge Summary
• Reiterate the chief complaint and resultant
etiology or suspected etiology (“evidence of”)
and note when symptoms of this condition
were present on admission
– Patient presented with XYZ secondary to
underlying admitting diagnosis of XYZ
– Patient admitted due to XYZ as evidenced by XYZ
presenting symptoms
Discharge Summary
• List all the diagnoses that were evaluated stating
which diagnoses were ruled out and which were
treated
• Differentiate new conditions that required
workup from chronic conditions that were
exacerbated or progressed during the admission
• Be sure to know when the patient required
“monitoring” for a condition e.g., cerebral
edema, as it may appear that treatment was not
rendered
Discharge Summary
• Include any “suspected,” “likely,” “probable,”
or “possible” diagnosis that will require
additional care following discharge
• Always note when the patient requests
discharge prematurely
• Always note the patient’s condition upon
discharge, verifying the patient was “medically
stable” or “palliative care,” etc.
Clinical Documentation Improvement (CDI)
• The CDI staff is composed of nurses (and
coders) that will help you translate the
complexity of your patients into diagnoses
that can be captured by ICD-9 codes (Call 5555555)
• Both quality measures and reimbursement are
dependent upon ICD-9 code selection
Chart Queries
• Whenever there is clinical evidence suggestive of
a more definitive principal diagnosis and/or the
presences of an incomplete or missing diagnosis,
the CDI nurse will “query” the physician for
guidance in interpreting the clinical evidence.
• You can always disagree or state the condition
isn’t clinically significant or is an incidental
finding
• Coders can’t infer or assume, so sometimes CDI
staff must ask for documentation that seems
obvious and/or ask you to “link” a symptom to a
diagnosis
Chart Queries
• Include information about your organization’s
query process
– Verbal, paper, electronic?
– Can the medical staff document on the query form?
• Part of the medical record or not?
– How does the medical staff respond to a query?
• Is there a timeframe in which they can respond?
– What does the provider do if he/she has a question?
– Is there a query escalation process?
An Example of Elements to Include:
Response to a Queries
The response time goal for queries is < 24 hours
A response should be made to every query whether you agree or
disagree
– If you agree, please update the chart to address the queried
issue even if the issue has been resolved
• Add to the next progress note
– Example  “Resolved acute respiratory failure”
• Add to discharge summary
– Example  “Experienced acute respiratory failure; resolved
with . . . (tx)”