Guest post: What is clinical validation

By Cathy Farraher, RN, MBA, CCM, CCDS for ACDIS CDI Blog

What is clinical validation and why is it important right now? The following quote from the June 2014 edition of Perspectives on Health Information Management sums it up in a nutshell:

“Documentation is an important aspect of medical care. In addition to clinical communication, documentation is coded to provide data that support quality metrics, acuity of care, billing, and accurate representation of medical conditions.”

Anyone even remotely involved in CDI, from the executives guiding its focus, to the CDI staff members performing the query process, and everyone else in the middle, needs to have some understanding of clinical validation and how it fits into the concurrent medical record review process.

Change is a difficult process for all involved. The executives are accustomed to reviewing metrics that indicate a positive shift in the case-mix index. The following example, taken from the July 2014 edition of Perspectives in Health Information Management illustrates how a program educated the neurosurgery department, tracked results, and saw shifts in its CMI data.

“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.”

In addition to the tradition MEAT (monitored, evaluated, assessed, treated) documentation advice for physicians, the “Pediatric Toolkit for Using the AHRQ Quality Indicators: How to Improve Hospital Quality and Safety” includes the following excellent rules to live by in the world of medical documenting:

• Avoid abbreviations and symbols.
• Write complete SOAP (subjective, objective, assessment, and plan) notes.
• Avoid using copy and paste when using electronic documentation.
• Be thorough when making selections from “pick-lists” embedded in electronic records.
• Become familiar with rules and concepts of documentation and coding.
• Be accurate and comprehensive; your documentation should “tell” the patient’s clinical story of his or her conditions, treatments, and outcomes.
• Document a thorough history and physical.
• Document the outcomes of “rule out,” “consider,” and “possible” diagnoses.
• Identify the principal diagnosis or reason for admission.
• Include all secondary diagnoses and conditions that affect patient care or the clinical decision-making process.
• Document the reason for and objective of all operating room (OR) and non-OR procedures performed; this is particularly important with ICD-10-PCS code assignment.
• Answer all queries for clarification promptly and fully. Be sure to document the clarification or additional information in the medical record.

It’s likely that many of these suggestions already represent core elements of your CDI program’s review efforts, but they could also have a positive effect on the clinical validation of the medical record.

Our job as both CDI specialists, and the leadership running these programs, is to educate all clinicians and executives regarding the importance of adjusting their focus to broadly encompass quality, accuracy, and specificity when reviewing and assessing their programs.

We already know that CDI programs can be an effective way of making sure that all possible diagnoses being evaluated, monitored or treated are included in the coded data, but we also need to make sure that our efforts are pure, and not muddied by the expected enthusiasm of the finance department, and that the diagnoses documented by the physician are supported by the clinical indicators in the medical record—that’s what clinical validation effort in CDI is all about.

There are many reasons for the existence of the validation query, but first and foremost is to maintain accuracy in the chart, which setting those early financial incentives aside, should be the end result of CDI efforts overall.

I would argue that CDI validation querying is the way of the future if we are to maintain compliance and ensure that our charts contain the purest form of the diagnostic data possible.