Interventions to improve documentation in the preoperative evaluation clinic significantly increased the total number of coded diagnoses and hierarchical condition categories per encounter (P<.05).
Cohort
No
Do interventions to improve documentation in the preoperative evaluation clinic increase the number of coded diagnoses and hierarchical condition categories in high complexity surgical patients?
Improved documentation in the preoperative evaluation clinic provides a more accurate clinical depiction of patients, positively impacting inpatient-adjusted surgical risk and quality outcome measures.
p-value: p=<.05
Objective To prove that inpatient-adjusted surgical risk and quality outcome measures can be considerably impacted by interventions to improve documentation in the preoperative evaluation (POE) clinic. Patients and Methods We designed a quality improvement project with a multidisciplinary team in our POE clinic to more accurately reflect surgical risk and impact expected surgical quality outcomes through improved documentation. Interventions included an improved patient record acquisition process and extensive POE provider education regarding patient comorbidities' documentation. For patients admitted after their planned operations, POE clinic comprehensive evaluation notes were linked to inpatient History and Physical notes. High complexity patients seen from October 1, 2018 to December 31, 2018 were the preintervention cohort, and the patients seen from January 1, 2019 to December 31, 2019 were the postintervention cohort. Results The primary outcome measures included the total number of coded diagnoses per encounter and the number of coded hierarchical condition categories per encounter. The secondary outcomes included the calculated severity of illness, risk of mortality, case-mix index, and risk-adjustment factor. Postintervention results show statistically significant increases in all primary outcomes with a P <.05. All secondary outcome measures reported positive change. Conclusion Our interventions confirm that a comprehensive POE and thorough documentation provide a more accurate clinical depiction of the preoperative patient, which in turn impacts quality outcomes in inpatient surgical settings. These results are impactful for direct and indirect patient care and publicly reported hospital and provider level performance data.
Smerina et al. (Fri,) conducted a cohort in High complexity patients undergoing planned operations. Documentation improvement interventions (record acquisition and provider education) vs. Preintervention standard documentation was evaluated on Total number of coded diagnoses per encounter and the number of coded hierarchical condition categories per encounter (p=<.05). Interventions to improve documentation in the preoperative evaluation clinic significantly increased the total number of coded diagnoses and hierarchical condition categories per encounter (P<.05).