Q&A: Templates for notes and findings

Q: We are currently seeking out best practices for templates regarding CDI reviewer notes and adding findings. How do different organizations template CDI reviews and add findings? Would anyone be willing to share some templates that your team uses?

Response #1: Here is our template for CDI review notes with examples of info suggestions:

• Admit Source: Non-healthcare, transfer from skilled nursing facility (SNF) or intermediate care facility (ICF), transfer from a hospital (different facility)
• Admission Type: Emergency, urgent, elective/routine (determines patient safety indicator [PSI] inclusion)
• Admit risk of mortality (ROM)
• Note to coder
• Assigned principal diagnosis
• Support for selection: Sepsis—second pneumonia, vasopressors, antibiotics VS-HR 120s, temp 102.5, WBC 22
• Monitoring for/potential query
• NRQs
• Assigned MCC with clinical indicators:
   
  • Sepsis— second pneumonia, vasopressors, antibiotics VS-
  • Diabetic ketoacidosis—gl 550, PH 7.25, Betahydroxybutyrate- 2.8, +ketones, Insulin infusion, Endotool
  • Acute respiratory failure—second pneumonia, vent management
  • Shock—Distributive, meds versus sepsis*, vasopressors
  • Pneumonia—Bacterial, vent management, antibiotics
  • Acute on chronic congestive heart failure (CHF)—History of, diuresis, history of CHF, BNP 1250, cardiology consult
    • NSTEMI—trop peak 3.4, c/o CP, heparin infusion, cardiology consult
• Assigned CCs with clinical indicators:
   
  • Acute kidney injury—Creatinine peak 2.81, baseline 1.1 –meets KDIGO- IVF, serial labs
• Activity associated with unsupported diagnosis—clinical validity process
• Specify documentation for reference by coders/other reviewers
   
  • Nutrition consult diagnosis (malnutrition): Moderate protein calorie malnutrition
    • MD diagnosis: none-manual nrcdi sent
    • Match with registered dietitian notes
  • Wound care skin integrity flow sheet: DTI buttocks hospital-acquired
  • Wound consult:  DTI buttocks hospital-acquired, present on admission no
  • MD diagnosis: None, query sent
• PSI information:
   
  • Validation of inclusions
  • Exclusions
  • Notification to quality

Response #2: We have specific documentation guidelines for the notes, the clinical criteria for sepsis principal diagnoses, and CC/MCC capture. We currently do individual personalized templates for all CDI specialists; however, when I educate new specialists, or even tenured ones, I do try to get them to do their new review findings/notes as follows:

XX(age)YOF(sex) presented to the ED/hospital c/o XYZ.

PMHx:

Dx:

-Reviewed: Emergency department (ED) note, history and physical (H&P), cardio consult, and progress note (PN) 02/29, PN Dr. Z 02/29

I personally find that using the format above saves time on rereviews/concurrent reviews and provides an overview of what the patient came in for, as well as relevant past medical history (e.g., surgeries, chronic conditions, social status such as homelessness, smoker, former smoker, quadriplegic, etc.). For “Dx” I include the acute diagnoses they were found to have once they were worked up. For follow-up/concurrent reviews, I have a different format, as noted below:

03/01 (date)

-Dx: (Any new diagnoses that were added, I also include not present on admission when condition was not present on admission)

-Reviewed: PN Dr. Z 03/01, ortho consult, op report 03/01 (any new documents that were added that I reviewed)

-Ortho consult Dr. A 02/27: Acute blood loss anemia

If there is any important or relevant statement that I know may come into play later, I will note it as well, including the document, date, and doctor who said it. Doing this will likely make my life easier later if I am debating on sending a query.

Response #3: Here is our initial review template:

Follow-up and query opportunities:

OBS Date:                      INPT Date:

Presentation/ED impression:

Vital signs (VS)

Body mass index (BMI)

Glasgow Coma Scale (GCS)

Sepsis alert

Labs/imaging (WBC, Neut, H&H, Plt, NA, K, BUN, CR, GFR, BS, and any others pertinent to condition)

Significant past medical history/home meds/treatment/therapy (pertinent medications to condition and CHF, B/P, DM, antibiotics immunosuppressive therapy)

H&P/consult impressions/progress notes:

Nursing/dietary/physical therapy/wound

Procedures

Clinical support for high-risk diagnoses

• Sepsis
• Acute hypoxic respiratory failure
• Malnutrition
• Encephalopathy
• AKI/ATN

Here is our follow-up review template:

Follow-up and query opportunities

Meds/treatment

Vital signs

Labs/imaging

Updated notes

Clinical support for high-risk diagnoses

• Sepsis
• Acute hypoxic respiratory failure
• Malnutrition
• Encephalopathy
• AKI/ATN

Specialists are permitted to individualize their templates; however, the key information needs to be captured either way.

Response #4: Below are the templates we are currently using:

Initial review:

• Chief complaint/signs and symptoms/pertinent history
• Labs/tests
• EHR info
• Consults
• Procedures
• Query alerts
• Hospital-acquired conditions (HAC), PSI, potentially preventable complications (PPC)
• Potential queries
• Focus of next review

Subsequent review:

• Case update
• Labs/test
• EHR info
• Procedures
• Consults
• Query alerts
• HAC, PSI, PPC
• Potential queries
• Focus of next review

Response #5: Our template possesses an “add finding” functionality which allows for the ability to document clinical findings that are discovered during the CDI review process:

Initial review: Please address each item

• Chief complaint/reason for presentation, include signs and symptoms, initial impression, was patient in observation status, reason for inpatient?
• Principal diagnosis: Any opportunities to change? Pending tests?
• CC/MCCs: Validation of diagnosis (support with indicators)
• Query opportunities (reasoning why query was not sent)
• Significant findings not related to above (vital signs, labs, ancillary notes, etc.)
• PSI/HAC findings, if applicable (comment on exclusion criteria, present on admission status, etc.)
• Focus of next review: What are you questioning and/or watching for

Continued review: No need to document each item listed below, unless it applies. Focus of next review is required.

• Review principal diagnosis: Solid or any opportunities to change?
• New CC/MCCs? Validation of diagnosis (support with indicators)
• New query opportunities (reasoning why query was not sent)
• New significant findings not related to above (vital signs, labs, ancillary notes, etc.)
• New PSI/HAC findings? (comment on exclusion criteria, present on admission, etc.)
• Focus of next review: What are you questioning and/or watching for?

Retrospective Review:

• Reason for review: (i.e., hospice/mortality, PSI, clinical validity, query response, etc.)
• Outcome of review
   
  • Hospice/mortality: Query opportunities not sent, please state why. If you get an unexpected response to a query that is impactful to the case, please escalate to physician advisor.
  • PSI/HAC: Make comments about exclusion criteria, present on admission, etc.
  • Clinical validity: Provide indicators that support diagnosis or send query.
  • Query response: Unexpected, inadequate responses, consider escalating for educational purpose.

Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council and originally appeared in the CDI Leadership Insider, the monthly council-only publication. For the purposes of this article, all Council member answers have been deidentified.