Clinical Documentation


Posted on Mar 2, 2018 in Clinical Documentation | 0 comments

The central line bundle will be followed. Refer to Infection Control “Central Line Associated Blood Stream Infections (CLABSI) Prevention Bundle” policy.

During insertion of the central line, the nurse will assist the physician and observe adherence to practices indicated in the Central Line Insertion Procedure (CLIP) checklist. The nurse will document in the e.H.R. CLIP checklist.

For PICC insertions, the PICC nurse will document in the e.H.R. CLIP checklist.

Prior to insertion of a CVC, patients and/or families are educated about CLABSI prevention.

When a line-related infection is suspected and cultures are indicated, refer to “Specimen: Culturing of Vascular Access Device” policy.

Veronica Bargas, RN

Kudos to Physicians with Excellent Verbal Order Signing Compliance

Posted on Jan 10, 2018 in Clinical Documentation | 0 comments

Universal Protocol Implementation

Posted on Oct 10, 2017 in Clinical Documentation | 0 comments

On behalf of Dr. Stephen Lockhart, MD, PhD, Chief Medical Officer, Sutter Health

Effective September 19, 2017, a new enhanced Universal Protocol was implemented in all Acute Care Hospitals and Ambulatory Surgery Centers that affect clinicians in surgical and non-surgical areas where invasive procedures are performed.

In 2016, an increased trend of wrong patient, wrong procedure, and wrong site events was identified within the Sutter system.  As a result, representatives from across the system came together to create a model process so that every patient will experience the same highly reliable process, every time, no matter where they undergo an invasive procedure in Sutter Health.

The Universal Protocol provides a process to ensure staff and providers catch potential errors before, during, and after the procedure. That way we ensure our patients receive the safest care.

We do many invasive procedures in non-surgical areas and the risk of having a ‘wrong’ event is as great in these locations. Therefore, these safety standards apply in all care areas where invasive procedures are performed. We understand that you and your team may have never experienced one of these events. The goal of the Universal Protocol is to ensure you never have to, because that pain is something no patient, no team, and no individual provider should have to endure.

Thank you for your support and active participation in these efforts to eliminate patient harm by incorporating these new expectations into your standard work.  Please note the following enhancements:

The Anesthesiologist signs the block site with the letter ‘B’ circled (see attachment for example)

  • The Anesthesiologist leads the team in the Sign-In
  • The Proceduralist marks the site in the pre-op area with their initials, or on body diagram
  • The Proceduralist leads the team in the Time-Out
  • The Registered Nurse leads the Sign-Out

With your support we can ensure that these ‘Wrong’ events become ‘Never’ events at Sutter Health and we can fulfill the trust our patients place in us when they select us to provide their care.

The below infographic highlights several key expectations incorporated into the new Universal Protocol 3 step process – Sign In; Time Out; Sign Out.  Please take a moment to review the highlighted areas on the attached document.






















Stephen Lockhart, MD, PhD
Chief Medical Officer, Sutter Health

Clinical Documentation Improvement CDI Update

Posted on Apr 7, 2017 in Clinical Documentation | 0 comments

In the past year there has been noticeable improvement in physician clinical documentation.

By this I mean that our documentation is more precise as more of us indicate Acuity, Co-Morbidities, Linkage and Specificity for each diagnosis. (I call this mnemonic “the other ACLS”).

For example: in the case of your patient with COPD who uses oxygen at home and is a CO2 retainer who is admitted because of increasing dyspnea, worse ABG, unchanged CxR, you would document “acute on chronic hypoxemic and hypercarbic respiratory failure due to an acute exacerbation of COPD”.

In order to build on this improvement trend, Sutter has contracted with Nuance Corporation to assist physicians with ongoing clinical documentation optimization. The service is in the form of CDI queries—these are similar to the existing Sutter CDI queries, with a somewhat simplified format. For now, you might see both types of CDI queries. You will find these queries in the “progress note” section in EPIC. The important thing is to answer the queries promptly, so remember to check your inbox for unanswered queries before you go off service. (CDI queries are usually generated while the patient is still in the hospital, whereas coding queries are sent by coding personnel and are created after discharge).

 I cannot overstate how much physician documentation matters—it’s the way we convey how ill our patients are and verifies our treatments and our patients’ clinical progress. Our documentation also affects assignment of proper DRGs, severity of illness and risk of mortality scores and observed:expected calculations and other quality metrics.

 CDI queries can serve as educational reminders to make sure our documentation is as accurate and complete as possible.

 From Merry Beth Gong, MD, CDI Physician Champion



Transfusion Risks

Posted on Jan 3, 2017 in Clinical Documentation | 0 comments

Please click on link for the Epic Transfusion Risks:

From Annette Shaieb, M.D.
Medical Director, Clinical Laboratory

Understanding Clinical Documentation Integrity/Improvement

Posted on May 5, 2016 in Clinical Documentation | 0 comments

The transition to ICD-10 necessitates that physicians document more precisely, completely and consistently than before.

Clinical Documentation Integrity/Improvement (CDI) is the link between physicians and the coding department. Coders translate physician documentation into ICD-10 codes.

These codes are the basis of MS-DRG assignment, severity of illness, other risk rankings and observed:expected mortality scores.

Because coding terms are often not the same as commonly used clinical language, it’s not always obvious how to best document a condition. When clarity is needed, a query is a way to obtain this information.

There are two types of queries—CDI and coding. The former usually occurs during the hospitalization, the latter occurs after discharge. Queries aren’t trying to question your diagnosis, they are to help optimize your documentation.

Try to answer the CDI query promptly. Any clarified diagnoses should then be documented in the progress note and discharge summary.

If you don’t understand the query, contact the CDI team, especially before selecting the “unable to determine” option.

At Summit, call Ext. 7945 or 7946 to reach Sandra Christensen-Waldear, R.N., or Jane Banks, R.N., and 510-612-7085 to reach Beth Gong, M.D.

Please document diagnoses rather than just symptoms and lab findings (e.g. “pneumonia” rather than

“infiltrate and cough” and “lactic acidosis” rather than “elevated lactate”)

ICD-10 is about specifics such as acuity, type and etiology. For example, “acute diastolic heart failure due to rapid atrial fibrillation” is more specific than “CHF and atrial fibrillation”)

Clearly state conditions present on admission (POA) —especially catheter-related infections and pressure ulcers. Physicians should document the location of the ulcers but can leave the staging to the wound R.N.

It is important to be clear when there is an association or linkage between conditions. For example, it is clearer to the coder if you document “gastroparesis due to type 2 diabetes” rather than “gastroparesis in the setting of diabetes” or “diabetes and gastroparesis.”

When there is diagnostic uncertainty, inpatient coding allows for use of modifiers such as “suspected,” “possible” and “probable.” If a diagnosis remains “likely” or “suspected” at the time of discharge, be sure to document this in the discharge summary. Similarly, be sure to document when such diagnoses are “ruled out.”

Just because we can copy and paste, doesn’t mean we should. Without careful editing, inaccurate and outdated information keeps moving forward with copy and paste.

Specific words matter—physician documentation should be complete and precise for both the principal diagnosis as well as all the secondary diagnoses and co-morbidities—this is how you show how sick your patient really is.

By Beth Gong, M.D.
CDI Physician Champion, Alta Bates Summit