Published on February 24, 2014
Utilising Coder Expertise in Clinical Documentation Education Tracey Matthies Senior HIM Sunshine Coast Hospital & Health Service Queensland Health
Reason for Admission/Presenting Problems Referred by GP for episode of hypertension Medications at Admission Nil Entered Principal Diagnosis Probably not pre-eclampsia Medications at Discharge Nil Entered Other Active Problems Nil Entered Medications Ceased this Admission Nil Entered Previous Medical History Previous history of pre-eclampsia requiring ICU admission Adverse Reactions Nil Entered Inpatient Clinical Management Admitted under obstetric team for assessment and observation Alerts Nil Entered Complications Nil Entered Procedures Performed Nil Entered Pathology Nil Entered Medical Imaging Nil Entered Significant Other Investigations Nil Entered Follow Up Arrangements Nil Entered Recommendations to GP Nil Entered Yeah, not so good….
Reason for Admission/Presenting Problems CT guided lung biopsy to investigate lung nodule Significant Other Investigations Nil Entered Principal Diagnosis Lung nodule Medications at Admission Aspirin – Codeine Other Active Problems Nil Entered Medications at Discharge Nil Entered Previous Medical History COPD Hypertension Family history lung cancer – yearly CXR to monitor Medications Ceased this Admission No medication changes Inpatient Clinical Management Admitted under Respiratory for lung biopsy Right pneumothorax after his lung biopsy - ICC inserted with resolution of pneumothorax Episode of bradycardia following the ICC insertion – ECG reassuring but right bundle branch block noted Transferred to ward for overnight stay due to pneumothorax Pain treated with paracetamol and opioids CXR in morning revealed resolution of pneumothorax – discharged home Complications Large right pneumothorax post lung biopsy 325mg/8mg tablets Adverse Reactions Nil known Alerts Nil Entered Follow Up Arrangements Respiratory physician will call patient early next week to discuss the results of the lung biopsy and make further follow up as indicated Recommendations to GP Monitor RBBB and follow up as required Procedures Performed ICC Recommendations to Patient Take analgesia as required to treat pain Respiratory physician will call next week to discuss results of biopsy Pathology Lung biopsy results pending Care Plan Summary Analgesia as required to control pain associated with biopsy Medical Imaging CXR CT Guided Drain/Aspiration CXR 15/01/20xx 15/01/20xx 16/01/20xx Way better!
Passive Learning Not really getting the message through
Active Learning Got their attention now!
Advertising The workshops bring together the expertise and perspective of senior Consultant, General Practitioner and Clinical Coder. A supportive yet challenging environment for the students to write real discharge summaries from real health records and get instant feedback from three of their most important readers
Interactive Workshop Sunshine Coast Hospital and Health Service in conjunction with the University of Queensland, School of Medicine, Sunshine Coast Clinical School „Interactive with immediate feedback, best “on the job” type teaching we‟ve had‟
Interactive Workshop The Educators Specialist Medical Officer (SMO) General Practitioner (GP) Enterprise Discharge Summary Facilitator (EDS) Clinical Coders The Students 4th Year Medical Students „Different perspectives from coders, medical staff and GP. Practical experience in using / troubleshooting EDS. This was a great session – would recommend every 4th year do it.‟
Interactive Workshop Materials: EDS Guidelines Computers Health Records „Real charts from your ward – very meaningful‟
Interactive Workshop Format Group Discussion - Role of health record documentation - Various readers and their expectations - GP expectations & professional courtesy EDS system overview - Layout - Feeder systems - Short cuts „Very clear information and relevant info. Different staff to provide different views about what‟s important to them‟
Interactive Workshop Format (con’t) Writing the discharge summary - Abstracting information from the health record - Presenting information on the discharge summary Discharge Summary Reviews - Critiquing a few „Incredibly relevant and real practice doing reports with direct feedback‟
Interactive Workshop Discussions that arose What is considered relevant information Where should it go – PD, AD, complication Writing a diagnosis not a value Gleaning information from progress notes The discharge plan – instructions, medications Deceased patients „Practical; provided a number of different perspectives on discharge summaries and the importance of doing them correctly‟
The expertise the coder can share Trust me I‟m a Coder
The expertise the coder can share Definition of terms used in the discharge summary – Principal Diagnosis – Other Active Problems (AD) „Good structure provided that is not otherwise taught‟
The expertise the coder can share Explaining the format of the discharge summary – – – – – – Reason for Admission/Presenting Problem Principal Diagnosis Other Active Problems Previous Medical History Inpatient Clinical Management Complications „Great friendly coding staff were very helpful. Interactive‟
The expertise the coder can share Identifying the diagnoses to include – Including providing a diagnoses not a value „Very practical and from workers in area e.g. GP, coders‟
The expertise the coder can share Explaining where to find the information in the health record – Pointing out the relationship between progress notes and discharge summary „Interactive. Lots of advice / people to ask for help‟
What the Coder Learns
What the coder learns They have strong skills to share - Coders are the expert readers Coding is all about summarising clinical concepts Coders are expert abstractors Coders know their way around a health record „Great session to debunk the fear of the unknown!‟
What the coder learns How a clinician thinks when they are documenting - - They don‟t have a full awareness of who is going to be reading it or why They don‟t think like a coder (coders want the outcome clinicians want the detail) - They don‟t use coding language so learn to translate „Range of expert opinion to give and wider understanding and diversity of expectations (e.g. consultant / GP / coders‟
What the coder learns They can develop professional relationships with clinicians - They are professional/experts within their own field and can be respected for that Clinicians are willing to work with coders and take direction „Good use of GP, coders and clinicians‟
Building the Relationship and Skills
Building the Relationship and Skills Effective documentation queries - - Now that the clinician knows who you are and what your purpose is he will read your query Identifying if a query to the clinician is required Writing a query in the clinician‟s language Constructing the question to get an answer Using documentation queries to provide feedback on documentation quality
Query: Could you please confirm if depolarisation (as per the codes below) is the same as repolarisation? There doesn't seem to be a code for Repolarisation that I can use. If it is the same then you may be able to recommend the best one to use. We have been asked to use Chest pain as a last resort if no cause is documented so if these terms don't have the same meaning then you may be able to suggest an alternative. Yeah, not so good….. Response: Physiologically depolarisation and repolarisation are not the same thing. Without context I couldn't tell you what to code for repolarisation. I don't remember this gentleman and without his chart I couldn't offer any more suggestion as to whether chest pain was appropriate. Sorry.
Query: Admission for bilateral inguinal hernia repair with no hernia found. There was documentation on the op report of sigmoid epiploic appendage adhered to deep ring- resected free, some omentum adhered to right deep ring but no hernia present. My questions relating to this procedure and the findings: 1. As no hernia was found, what was the presenting symptoms? 2. After study, has there been any formal diagnosis to explain the cause of the presenting symptoms? Way better! Response: Give me a call if it is confusing 1. I think still we can say hernia was present in both side, because in some cases we cant see a peritoneal sac. 2. I think those fat and epiploic appendage was herniating, so B/L hernia is the diagnosis
Building the Relationship and Skills Participating in clinical meetings and clinical education - Clinicians appreciate the value of having coder input into documentation Clinicians want to utilise the abstraction skills of a coder
Suggestions for improvement • „Doing a practice case together in the start to practice extracting data‟ • „Structure of charts and tips for sourcing patient info‟
1. Utilising Coder Expertise in Clinical Documentation EducationTracey Matthies Senior HIM Sunshine Coast Hospital & Health Service Queensland Health
Tracey Matthies Sunshine Coast Hospital & Health Services - Utilising Coder Expertise in Clinical Documentation Education
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