ICD-10, Meaningful Use and integrity/quality initiatives have recognized the need for and contributed to the impetus for improved clinical documentation.  Good clinical documentation is a critical element in delivering patient care.  Complete and accurate documentation validates the care provided shares key data with subsequent caregivers and allows coders to code accurately to ensure the hospital is fairly paid.  While payment may not be the focus when providing healthcare, good documentation remains an arguably strong link to financial performance, which subsequently impacts the ability to continue to provide healthcare services.

Despite the importance of good documentation, Clinical Documentation Improvement Specialists (CDIS) and coders often lament about the challenges they face obtaining better information from documenters.  But why does this challenge exist if we all agree that good documentation is important?  The answer lies in the fact that “good documentation” has changed throughout the tenure of most physicians’ practices.  Physicians are busy with their patients and while CDI specialists and coders are solely focused on the documentation, physicians often document enough for fellow clinicians to know what’s happening.  As such, what a physician considers “enough” may be insufficient for coders and not meet the required standard.  Furthermore, because physicians tend to speak their own language – not always shared by payers – a request for more information may receive a response of “read my note,” and any challenge to the inadequacy of current practices may be met by “show me where I did that.”

This seemingly simple statement highlights one of the important benefits of documentation audits.  Audits facilitate a detailed examination of records, particularly post discharge, and give reviewers the opportunity to identify documentation improvement and query opportunities.  This can be linked and compared to final coding for a financial impact analysis.  However, this should not be the end.  Physicians, coders and CDI specialists can and should all receive training based on audit results.  For physicians, using examples directly from their record is the most beneficial.  Showing them their record in comparison to the desired documentation will reduce resistance and reinforce training concepts.