Clinical Documentation

DR. ARETHA ANN GACUTAN-LIWAG, MD, MSc,MHA, FPSQua, FPCP, FPCEDM

Head, Professional Education and Training Office – Quality Assurance(PET-QA)
OIC Head, Research and Extension Office
WVSU Medical Center
 What is Clinical Documentation ?
 Why document ?
 Laws governing Clinical Documentation
 Clinical Documentation Standards
 Clinical Documentation Improvement
What is clinical documentation?

 Clinical documentation is any manual or electronic notation in a patient's

chart made by a clinician related to a patient's medical condition or
treatment. Quality clinical documentation is the basis of accurate health
data.

Clinical Documentation: The Foundation of Health

System Data
https://www.cihi.ca
What is the significance of clinical
documentation?

 The primary purpose of clinical documentation should be to support patient

care and improve clinical outcomes through enhanced communication. The
primary purpose of clinical documentation is to facilitate excellent care for
patients.

Thomson Kuhn, MA. Clinical Documentation in the

21st Century: Executive Summary of a Policy
Position Paper From the American College of
Physicians. https://doi.org/10.7326/M14-2128
Purpose of Professional Documentation

 Communication
 Accountability
 Legislative Requirements
 Quality Improvement
 Research
 Funding and Resource Management

Guidelines for Medical Record and Clinical

Documentation WHO-SEARO coding workshop September
2007
DOH Rules and Regulations on
Hospitals
Policy objective:

to protect and promote the health of the

public by ensuring a minimum quality of
service rendered by the hospitals and other
regulated health facilities and to assure the
safety of patient’s and personnel.
 STANDARD CRITERIA INDICATOR

The organization has a planned Continuous Quality Improvement Presence of Quality Improvement
systematic organization-wide Program Program
approach to process design and
performance measurement,
assessment and improvement

Appropriate professionals
perform coordinated and
sequenced patient assessment to
reduce waste and unnecessary
repetition
Nurses make use of nursing Charts have nurses’ notes
process in the care of patients Presence of Nursing manual and
properly utilized Kardex

Medicines are administered in a Medicines are administered in a All medicines are administered
standardized and systematic timely, safe, appropriate and observing the five (5) R’s of
manner. Diagnostic examinations controlled manner medication which are:
appropriate to the provider 1. Right patient
organizations service capability 2. Right Medication
and usual case mix are available 3. Right dose
and are performed by qualified 4. Right route
personnel. 5. Right time
 STANDARD
Each Patient’s Physical,
Psychosocial and Social status is
assessed.
Appropriate professionals
perform coordinated and
sequenced patient assessment to
reduce waste and unnecessary
repetition
The discharge plan is a part of
the patients care plan and is
documented in the patients’
chart
Clinical records are readily
accessible to facilitate patient
care are kept confidential and
safe, and comply with all
CRITERIA INDICATOR
An appropriate comprehensive All patients have comprehensive
history and physical examination is history and PE within 48 hours
performed on every patient within from admission
48 hours from admission. The
history includes present illness,
past medical, family, social and
personal history.
Previously obtained information is All patient charts have progress
reviewed at every stage of the notes by doctors and other health
assessment to guide future professional
assessments
Discharge plans for patients to All charts have discharge plans
ensure continuity of care
Electronic Medical records All general and specialty hospitals
are mandated to comply with the
EMR implementation.
EMR – e-claims, primary care
Philippine Health Records Standard
include:
 Licensing Standards as defined in Administrative
Order 2012-0012
 International Health record Standard as defined
by the Joint commission International
Accreditation Standards
 PhilHealth Benchbook
 International Organization for Standardization
(ISO 9001:2015)
Other regulatory/mandatory policies;
RA 10173 – data privacy act of 2021
RA 11223 Universal Health Care Act
AO 2013-005 National Policy on the unified
disease registry system of DOH
RA 9470 National Archives Act of the
Philippines 2007
The contents of Patient’s chart:
 Face sheet
 Informed consent
 History of the physical examination
 Doctor’s order
 Nurses notes
 TPR sheet
 Laboratory report
 Imaging reports
 Maternal record with partograph
 Newborn record and maturity rating
The contents of Patient’s chart:
 Medication/treatment record
 Operative and anesthesia record
 Record of interdepartmental referral/consultation
to other physicians, including notes
 Record of referral or transfer of patient to other
facility/service/doctor including notes
 Discharge summary
 Clinical Abstract
 Advance directive
 15
1. There must be a health record for each
patient confined/treated in the healthcare
facility.
2. Documentation in the health record must
General Guidelines on
Documentation of
reflect the patient’s physical condition,
Health Records: and the orders and care provided from
admission to discharge.
3. Documentation in the health record must
reflect the patient’s physical condition,
and the orders and care provided from
admission to discharge.
 16
4. Documentation must reflect observation
and must be objective and non
judgmental.
General Guidelines on 5. There must be a standard format for
Documentation of health record documentation by the
Health Records:
physician and other interdisciplinary
team members who participated in the
care of the patient.
6. All documents must be legible and
written in ink or typewritten.
 17

7. Any person making an entry on the health

record must put date and sign his/her entry
or properly authenticate the entry made.
General Guidelines on 8. Documentation of the inpatient health
Documentation of record must be completed within 48 hours
Health Records: upon the patient’s discharge. History and
Physical Examination must be completed
within 24 hours upon admission of the
patient. However, outpatient health records
must be endorsed to the HIMD daily.
 18
9. Every healthcare facility must develop an
ongoing review of health records to assure
quality documentation. This must be one of
the major functions of the Medical Records
General Guidelines on
Committee.
Documentation of
Health Records: 10. It must be the policy of every healthcare
facility not to allow the use of abbreviations
in writing the diagnosis. But for symbols
which might be written by the authorized
person, an explanatory legend shall first be
approved by the said healthcare facility.
 19
11. Short forms like laboratory and
other results must be securely
fastened to the health record to
prevent loss.
General Guidelines on
Documentation of
Health Records: 12. The health record is a legal
document, so no form maybe
detached once it is filled.
Furthermore, there must be no
erasures of any sort.
 20

01 02 03
In order to correct an
Draw a single Affix the Write the
error, the following line through the attending correct entry
shall be done: information to physician’s near the
be corrected or initial, date and information to
changed time be corrected
 21
13.In cases where the patient wants some
data corrected especially on the
demographic/sociological data, the
correction should not be done on the
General Guidelines on
Documentation of
original entry, but shall appear as an
Health Records: amendment only.
14.The health records must contain all original
copies of examination results, operations
and other required forms.
 22
15. The inpatient health record must be completed
and it must include the following forms properly
accomplished, signed and dated.

General Guidelines on Patient’s data sheet - (name, address and other social data)
Documentation of
Health Records:
Admitting and final diagnosis – description of any operation
and procedures performed

History Sheet – (chief complaint, personal and family history)

 23
d. Physical examination sheet – pertinent positive and negative
findings and impressions
15. The inpatient
health record must be e. Physician’s order – all doctor’s order
completed and it must
include the following f. Diagnostic and other report sheet – results of all laboratories,
forms properly radiologic and other procedures
accomplished, signed
and dated. g. Progress notes sheet – doctor’s positive and negative observations and
comments. Chronological picture of the clinical
condition of the patient.

h. Discharge Summary – significant findings and events that occurred

during the patient’s hospitalization, final
diagnosis, operation, complications, condition
upon discharge, OPD follow up treatment and
classification of injury (medico-legal case).

15. The inpatient health
record must be completed
and it must include the
following forms properly
accomplished, signed and
dated.
24
i. Anesthesia record
j. Report of an operation – authenticate a pre-operative diagnosis
before a surgery. (all findings, surgical technique, description f any
tissue removed and post-operative diagnosis.
k. Nurses notes – observations, treatment given, response to
treatment and any unusual occurrences.
l. Certificate of Live birth, Fetal and Death certificate
m. Other records – medication and treatment, vital signs record
 Guidelines for
Medical Record and
Clinical
Documentation WHO-
SEARO coding
workshop September
2007
https://occupationaltherapy20
12.files.wordpress.com/2012/0
3/2007_guidelines_for_clinical_
doc.pdf
Clinical Documentation Improvement

 process of reviewing medical record documentation for completeness and

accuracy. CDI includes a review of disease process, diagnostic
findings, and what the documentation might be missing. A CDI
specialist often has both clinical and medical coding backgrounds.
Bridging the gap between clinical documentation and accurate coding
drives CDI programs.
 A clinical documentation improvement program is a process designed and
implemented with the purpose of achieving accurate and thorough
medical record documentation.
 Why are CDI programs needed? In many ways, the use of electronic
health record (EHR) systems has eased the burden on providers and
hospitals of navigating the administrative duties surrounding patient
care and claim submission. However, the responsibility of medical
record documentation — the entry of clinical information concerning
care rendered to a patient — will always remain with the medical
provider. To help providers succeed in this task, a CDI specialist is
responsible for reviewing a patient’s medical record to ensure
documentation reflects the specificity of current conditions to allow
for accurate coding of the patient’s health status.
Benefits of CDI

 can improve the accuracy of coding and billing for

inpatient facilities, which will result in more accurate
reimbursement.
 benefit to the overall well-being of the patient is
significant

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Implementing a Clinical Documentation Improvement Program
 Accurate claim submission, favorable audit results, a healthy revenue cycle, and better
health outcomes for the patient are all reasons to implement a CDI program. CDI can be
challenging if all parties involved in implementing a CDI program (physicians, administrators,
CDI specialists, and coding and billing staff) do not understand the purpose and process of CDI
and how each role is vital.

52
5 Steps to Implement a Successful CDI Program

 1.Analyze why your facility/practice needs a CDI program.

 Asking these questions is a great start:

 What is the claim denial rate (return to hospital or disapproved claim ) ? What are the top reasons for
denials?
 What is the rate of admission to an acute care hospital for our patients with certain conditions (such as
respiratory or diabetic complications)?
 Are we meeting compliance and regulatory standards? Has a government (Philhealth / DOH) or payer (HMO)
audit identified deficiencies?
 Are we providing quality patient care to meet payer contract requirements? Are we meeting KPI measures?
Is our patient base susceptible to social determinants of health (SDOH) ?
 If the answer to any of these questions is less than favorable, then a CDI program may be warranted. Start
with the desired outcomes of the program then build the processes to achieve those goals.

53
5 Steps to Implement a Successful CDI Program
 2.Decide how CDI reviews are selected.
 inpatient CDI program may have EHR system alerts when a patient is admitted with
certain complicated diagnoses.
 outpatient program may have a policy to randomly select a sample of charts to review or
generate reports of certain diagnoses to perform more targeted reviews.
 3.Establish clinical standards. establish a decision-tree protocol ( clinical
pathways)
 4.Review the reviews
 is to evaluate not only the flow and results of the CDI program
 determine whether the process follows ethical standards.
 Use an analysis rubric to identify areas of improvement, nonbeneficial activities, and the
successful results of the program. Look for both the good and the bad practices
 5.Collaborate
 CDI specialist and the medical coder
 CDI specialist and the physician —

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Personnel – Medical Records Officer

Bachelor’s Degree
Training in ICD-10
Training in Medical Records Management
CDI Personnel – Medical Records Officer

 Bachelor’s Degree
 Training in ICD-10
 Training in Medical Records Management

 highly qualified professionals

Medical doctors
Nurses with coding experience
medical coders with CDI training
 What is Clinical Documentation ?
 Why document ?
 Laws governing Clinical Documentation
 Clinical Documentation Standards
 Clinical Documentation Improvement