Use of Standardized History and Physical Examination for Neurosurgical Patients Improves Clinical Documentation and Reimbursement
| Autor: | Rebecca R. Coffman, Laila Malani Mohammad, Fares Qeadan, Benjamin M. Vidalis, Kristopher T. Kimmell, Lida Fatemi |
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| Rok vydání: | 2021 |
| Předmět: |
medicine.medical_specialty
Physical examination Documentation Neurosurgical Procedures Academic institution 03 medical and health sciences 0302 clinical medicine medicine Electronic Health Records Humans Medical History Taking Physical Examination Reimbursement Retrospective Studies medicine.diagnostic_test business.industry Retrospective cohort study Reference Standards medicine.disease Social history (medicine) 030220 oncology & carcinogenesis Review of systems Insurance Health Reimbursement Surgery Neurology (clinical) Neurosurgery Medical emergency business 030217 neurology & neurosurgery |
| Zdroj: | World Neurosurgery. 148:e667-e673 |
| ISSN: | 1878-8750 |
| DOI: | 10.1016/j.wneu.2021.01.056 |
| Popis: | Background Documentation is the cornerstone of good patient care and vital to proper coding and billing. Consistent and standardized documentation improves communication among physicians and can lead to better reimbursement. By understanding which elements in the neurosurgery history and physical examination are omitted the most often and the effects on the coding level, institutional-specific solutions can be implemented. Methods We performed a retrospective study of neurosurgical patients at a single academic institution who undergone a neurosurgery history and physical examination for an initial inpatient admission from July 2015 to July 2016. The data collected included documentation type (typed, dictated, dynamic documentation without a template, neurosurgery history and physical examination template [NHPT]) and ultimate coding level (1, 2, or 3) determined by a review by a professional coder. Results A total of 609 notes were reviewed. Of the 609 notes, 88 (14.4%) were missing an element of documentation. The most common missing element was the physical examination (40 of 88; 45.5%), followed by a combination (27 of 88; 30.7%), review of systems (14 of 88; 15.9%), and medical, family, and/or social history (7 of 88; 8.0%). The dynamic documentation without template notes had the highest percentage of missing elements (49 of 96; 51.0%), followed by the typed notes (7 of 49; 14.3%) and dictated notes (30 of 268; 11.2%) compared with the NHPT notes (2 of 196; 1.0%). Conclusion The most common missing elements for inpatient neurosurgery documentation were the review of systems and physical examination. The documents with the highest percentage of missing elements were those that used dynamic documentation without a template. We recommend implementing a dedicated NHPT to improve capturing these elements for improved clinical documentation. Such changes could also improve the coding level and subsequent reimbursement. |
| Databáze: | OpenAIRE |
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