HCPro, JustCoding Inpatient - 2018 Issue 48 (November)
The impact of EHRs on your inpatient CDI efforts
November 27th, 2018
Subscribe or sign in to view the full article.
Article Overview
This article looks at the ways electronic health records can influence inpatient CDI operations, with emphasis on common documentation and workflow challenges that arise in electronic environments. It is intended for CDI professionals, coding staff, and clinicians who work with inpatient documentation and query processes. The discussion covers broad categories such as copy-and-paste documentation, note quality, template-related discrepancies, alert fatigue, implementation issues, and query transparency, along with general ways CDI teams may respond.
Why This Topic Matters
EHRs shape the quality and usability of inpatient documentation, which directly affects CDI review, coding accuracy, and compliance risk. Understanding the common problem areas helps CDI teams anticipate documentation issues and support better provider workflow.
Article Sections
-
Note cloning
Discusses copy-forward documentation patterns in the EHR and their effect on CDI review and provider workflow.
-
Note bloat
Covers how extensive copying of other documentation into daily notes can affect note usability and CDI review.
-
Legibility and clarity
Addresses the difference between readable documentation and documentation that is still ambiguous or incomplete.
-
Incongruity between diagnosis and physical exam
Examines mismatches that can occur between documented diagnoses and the recorded physical examination in the EHR.
-
Alert fatigue
Describes how repeated electronic alerts and pop-ups can reduce attention to CDI communications and other messages.
-
Usefulness of documents in the EHR versus on paper
Compares documentation quality and workflow differences between paper-based processes and EHR-based documentation.
-
Implementation disasters
Reviews the CDI impact of unsuccessful EHR implementation and the importance of planning before go-live.
-
Query transparency
Discusses how electronic records can affect visibility of CDI queries and the need for compliant query practices.
What You Will Learn
- How EHR design and workflow can affect inpatient CDI efforts
- Common documentation issues that arise in electronic charting
- Ways EHR features may influence query response and documentation quality
- General considerations for preparing and evaluating EHR implementation from a CDI perspective
- Why CDI teams should review documentation practices for consistency and clarity
Who Should Read This
- CDI professionals
- Inpatient coders
- Hospitalists and other physicians
- Clinical documentation integrity managers
- Health information management staff
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com