Quality Documentation

1. Quality Documentation • Accurately reflects the severity of a patient’s illness and the intensity of care being provided • Adjusts risks and sets proper expectations for patient outcomes and lengths of stay

2. Physician Profiling • Physician practice patterns are being tracked • Patient diagnoses and outcomes data are mined • Physician quality and cost efficiency are analyzed • Physician rankings/ratings are published online

3. Physician Profiling - Uses • Physician staffing/hiring decisions • Patient selection of physician/provider • Bonus/penalty assignment

4. Clinical Example – “Mr. Smith” • HPI: Patient with h/o CHF, HTN, CKD and medication noncompliance presents with • CC: Acute SOB, bilat LE edema • Lab: LVEF 55% BNP 24000; Cr 2.2 GFR 30 • Rx: IV Lasix 40 • Dispo: DC’d home on hospital day 4

5. Documentation Impact POOR GOOD Acute on Chronic Diastolic Heart Failure CKD, Stage 3 Expected Length of Stay = 5 Days • CHF “Exacerbation” fill ===er • CKD (unspecified) Expected Length of Stay = 3 Days

6. Clinical Documentation Education • Documentation Tip Sheet – (copies @ chiefs’ office) • Morning Report Presentations – (case examples, Q&A) • Clinical Rounds Participation

7. Clinical Documentation Staff • Freddy Santoso – (408) 885-5153 • HemlataPun – (408) 793-6583 • Mary Grace Tesoro – (408)-885-5133 • Terri Thomas – (408) 793-6171 • Diane Maley – Director • ChenTsen Shu – Physician Advisor