Health Information Management

Tip: Accurate documentation for terminal patients

CDI Strategies, June 6, 2013

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by Trey La Charité, MD

CDI professionals must educate facilities and physicians about the importance of accurately capturing the entire disease process  because physicians, unfortunately, are frequently reluctant to document additional disease  processes in the charts of patients who are obviously about to die. Let’s look at one example before discussing possible causes.

A CDI specialist reviews a case on the floor or in the ICU and notices “prognosis grim” written several times in the medical record. The physician, however, neglected to document one or more strikingly obvious diagnoses from the patient’s record. The CDI specialist queries the physician about the absent disease processes, asking whether those diagnoses are present and how they might affect the patient’s current clinical situation. The queries go unanswered. The CDI specialist follows up with the physician, which proves unproductive.
 
The physician replies, “I’m not going to write that. That patient is about to die.”
 
There are numerous reasons physicians take this position, and while this is not an exhaustive list, you may have heard some of these excuses at one time or another:
  • “I don’t want to ‘penalize’ the patient.”
  • “I don’t want to bilk the insurance company.”
  • “I don’t want to stick the family with a higher bill.”
  • “It just doesn’t feel right.”
  • “Why do you need that? They are going to die. How much sicker do you need them to look?”
By examining the faulty and misguided rationale behind these excuses, we can develop an appropriate response when confronted with a similar situation in the future.

Editor’s Note: This article is an excerpt from the April 2013 edition of CDI Journal. La Charité is a hospitalist with the University of Tennessee Hospitalists at the University of Tennessee Medical Center at Knoxville, and an ACDIS Advisory Board member. He is board certified in internal medicine and has been a practicing hospitalist since 2002.  Contact him at clachari@utmck.edu.



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