An Evaluation of a Clinical Documentation Improvement Program’s Impact on Sepsis Documentation, Coding, Quality Reporting, and Hospital Reimbursement

n Evaluation of a Clinical Documentation Improvement Program’s Impact on Sepsis Documentation, Coding, Quality Reporting, and Ho
Thesis
Description: 

The purpose of this study is to evaluate the impact of a new clinical documentation improvement program on sepsis documentation, quality reporting, and hospital reimbursement in three hospitals. A retrospective chart review was conducted of patients admitted through the emergency department with a urinary tract infection as the principal diagnosis, but without documentation of sepsis at three medical centers in San Diego from 2009 to 2014, in order to evaluate potential missed query opportunities to clarify the diagnosis of sepsis for coding purposes. The study included a purposive sample of 25 records pre and post-implementation of a Clinical Documentation Program, for a total of 50 records. There were no statistically significant differences between the pre and post-implementation groups with respect to the sample demographics or the number of documentation opportunities or sepsis indicators present, however, positive potential financial and quality impacts were realized. In conclusion, the implementation of a Clinical Documentation Improvement Program had no significant impact on the documentation of sepsis consistent with the latest published diagnostic criteria at that time. Limitations include a small sample size and variations in program elements and education at each facility. Further strategies to improve documentation need to be explored and future chart review studies should consider a larger sample size in order to evaluate the potential significance.

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WHDL ID: 
WHDL-00005500
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