I was a foreign medical graduate who in addition to some clinical practice, had begun a career first in managed care as a utilization management coordinator and then as a clinical researcher after finishing medical school and then pursuing a public health degree.

A few years ago, life took some unexpected turns, and I found myself in a rather new field of health care known as clinical documentation improvement (CDI). I did not understand why a physician’s note or what they documented was not always enough. I mean, they saw and treated the patient, isn’t their clinical judgment and competency sufficient?

Well as it turns out, a wise man or woman once stated: “If it was not documented, it was not done.”

Here is an example of what that means. You have a patient who comes in hypoxic, wheezing, possible pneumonia, he is desaturating and requires oxygen, or in some cases, even BiPAP or — worse yet — ventilation. You mention in your notes that he has “respiratory distress.”

This is where a clinical documentation improvement specialist like myself (You need to be either an RN or have a medical degree for this role in any respectable CDI program), will review the charts and ask a physician if this really is just distress or is it possible the patient can be going into a more serious condition, such as acute or acute on chronic respiratory failure? Again, the point is not to challenge a physician’s clinical acumen or judgment but instead make them think outside the clinical box and try to have them be a little more specific with what they really are diagnosing and treating.

As a physician, you may ask, “Well why do I need to waste my time documenting when I have to see so many more patients and the patient was given the proper care whether it was distress or failure?” The answer to that question, one that many a CDI, myself included, have been asked is, quite simply, the severity of illness and, possibly, the risk of mortality. What if this patient unfortunately expires? Were all their comorbidities documented? This also leads to the other piece of the puzzle, which is the big bad wolf of health care — reimbursement and denials. If the patient’s medical condition is not accurately documented in all charts, a provider risks medical necessity denials and lower reimbursements and lower quality scores. It is your documentation that leads to the correct DRG assignments and ultimately allows the coders to accurately code the charts before they are sent off to billing and the insurers.

Here is another favorite gem of mine in this wonderful world of medical charts: I once reviewed a patient’s chart when I first started my new-found career in clinical documentation improvement. The history and physical stated that the patient was a 60-something female who had come in for a certain chief complaint and was evaluated. Her gynecological history clearly stated she was menopausal. So, imagine the horror on my face when I read a subsequent progress note by the same physician stating the woman is eight-weeks pregnant. I do a double take, go back to the H&P and re-read that she is menopausal, and then in this note, it says she is eight weeks pregnant. I make my new trainee read the note just to make sure I am not incorrectly reading this chart, and he too has that same look of horror and confusion. We’re both medical doctors trying to make sense of what we have just read and brainstorm together to figure out a plausible explanation.

Is this a medical miracle or a medical error in documentation?

We both agree to discuss this chart at the next case conference with our supervisor, and she too is stunned. Eventually, we contacted the physician who wrote the two notes, and as it turns out, this was not a medical miracle, but a documentation error and a serious one at that. The physician admitted that in his haste to complete charts, he had two different patient charts open at the same time and had probably cut and pasted from the wrong chart into the progress note. He was advised to promptly correct the error in his notes before this chart was coded and billed. I will save the possible legal implications, physician documentation errors due to EHRs and the pressure to see too many patients in too short a time all for another discussion.

So, the next time you receive that pesky “query” from the CDI department in your facility, remember: documentation, documentation, documentation!

Rabia Jalal is a physician.

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