Perspect Health Inf Manag - Improving and measuring inpatient documentation of medical care within the MS-DRG system: education, monitoring, and normalized case mix index.

Tópicos

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Resumo

Documentation of the care delivered to hospitalized patients is a ubiquitous and important aspect of medical care. The majority of references to documentation and coding are based on the Centers for Medicare and Medicaid Services (CMS) Medicare Severity Diagnosis Related Group (MS-DRG) inpatient prospective payment system (IPPS). We educated the members of a clinical care team in a single department (neurosurgery) at our hospital. We measured subsequent documentation improvements in a simple, meaningful, and reproducible fashion. We created a new metric to measure documentation, termed the "normalized case mix index," that allows comparison of hospitalizations across multiple unrelated MS-DRG groups. Compared to one year earlier, the traditional case mix index, normalized case mix index, severity of illness, and risk of mortality increased one year after the educational intervention. We encourage other organizations to implement and systematically monitor documentation improvement efforts when attempting to determine the accuracy and quality of documentation achieved.

Resumo Limpo

document care deliv hospit patient ubiquit import aspect medic care major refer document code base center medicar medicaid servic cms medicar sever diagnosi relat group msdrg inpati prospect payment system ipp educ member clinic care team singl depart neurosurgeri hospit measur subsequ document improv simpl meaning reproduc fashion creat new metric measur document term normal case mix index allow comparison hospit across multipl unrel msdrg group compar one year earlier tradit case mix index normal case mix index sever ill risk mortal increas one year educ intervent encourag organ implement systemat monitor document improv effort attempt determin accuraci qualiti document achiev

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