Improving Your Clinical Documentation Quality for ICD-10

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Improving Your Clinical Documentation Quality for ICD-10 As the implementation date of ICD-10 is approaching, healthcare practices are required to improve their clinical documentation as soon as possible for adopting the coding changes. Due to the higher level of specificity, the quality of documentation is very important under the new coding system. For example, if you are documenting fractures, focus should be given for fracture type, laterality, episode of care and type of encounter since there are specific codes for all these items. Here are some steps to be taken for improving the quality of your documentation for ICD-10.

Gap Analysis Clinical documentation may lack specificity due to the following reasons. 

Not documenting disease type

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Not documenting disease acuity

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Not documenting site specificity

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Not documenting disease stage

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Not documenting laterality

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Not documenting one or more details for a combination code

www.medicaltranscriptionservicecompany.com Some healthcare organizations may struggle with all of these challenges while some may need to address one or two. With a complete documentation gap analysis, you can identify the challenges specific to your organization. A comprehensive crosssection of cases, inpatient, ambulatory, outpatient, and physician practices can help to identify areas for greater risk.

Standardization Documentation quality teams within the organizations should collect all the document types and other forms used throughout the patient care process in the relevant organization. Then they should determine which of them are still relevant, which need to be revised and which are obsolete. Based on this, they can derive a standard documentation policy viable for ICD-10. Standardized policy includes the standardization of content, structure and terminology. The quality team should find out the areas where this kind of standardization would be appropriate. They should also ensure that these standards are met and make improvements, if necessary through reporting and analytics.

Training Of course, the results of gap analysis and standardization will help organizations to find an effective way to improve their documentation for ICD-10. However, it requires efficient reference tools and training throughout the organization to

www.medicaltranscriptionservicecompany.com interpret the results and make improvements accordingly. By providing enough training to the staffs, healthcare organizations can build documentation habits and technology that improve efficiency and standardization. This will also support accuracy and completeness.

Technology Enhancement Healthcare organizations should make sure that the technology used is appropriate and configured optimally for the workflow and environment of a particular specialty.

For example, when it comes to documenting coma for ICD-10, it is required to document the Glasgow Coma Scale (a neurological scale that captures a patient’s conscious state for initial and subsequent assessment) while in the case of diabetes it is required to document the type or etiology of diabetes, body system affected, and any complications affecting that body system. Technology enhancement or optimization include the designing of EHR fields and templates, checking how various fields move from system to system via interfaces, processes for identifying errors that migrate across systems, management of speech recognition profiles and so on.

Even if you are using electronic health records (EHRs) with speech recognition system, the service of medical transcriptionists may be required to correct the errors made and ensure the accuracy of documentation. Therefore, you should give proper training to in-house transcriptionists as well or obtain the service of professional transcription companies. In either case, ensure that your quality standards are met.

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