Medical Student Medical College of Wisconsin Milwaukee, Wisconsin, United States
Introduction: Despite the known importance of accurate clinical documentation as a companion to quality patient care, it is not often prioritized in practice leading to a variety of downstream consequences. Inaccurate documentation results in missed opportunities for full, accurate coding. In turn, it also negatively influences hospital and physician quality rankings, medical center profiling, and revenue captured. This study seeks to highlight the opportunity for continued improvement in clinical documentation and the significance accurate clinical documentation has on outcome measures, such as expected length of stay (eLOS).
Methods: A single-center retrospective chart review took place for patients undergoing spinal surgery from 2019 to 2021. Based on the Vizient® Clinical Data Base (used with permission of Vizient, Inc. All rights reserved) diagnosis related group (DRG) risk models for eLOS, 192 charts spanning 10 unique DRGs were reviewed to identify ICD-10 diagnosis and procedure codes that were not coded or not clearly documented. A new eLOS for each patient was recalculated with the addition of the newly identified variables and then compared to the original eLOS.
Results: Overall, there was a significant difference between the original eLOS and new eLOS when the newly identified variables were added (p < 0.001). Of 192 patient charts, 89.5% had at least one new variable contributing to eLOS, with an average of 2.60 (0, 12) new variables. This resulted in an average increase in eLOS of 2.869 days (-0.160, 35.129). Compared to the observed LOS, the new eLOS was significantly different (p < 0.001), whereas the original LOS was not (p = 0.5661).
Conclusion : Incomplete documentation and coding can misrepresent the quality and complexity of patient care provided. This represents an opportunity for improvement for the clinicians, clinical documentation improvement specialists, and coders to improve quality metrics and hospital rankings.
