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The Clinical Documentation Specialist: A Key Member of Quality and Patient Safety Teams
By Paul L. Weygandt, MD, JD, MPH, MBA, CPE
Patient safety experts recognize that teamwork is essential to improve quality and patient safety, but is there a crucial member missing from the clinical team?
The principal focus of clinical teams should be on optimizing the quality and safety of patient care delivered. Analysis often begins with the review of a near miss or adverse event. Team members review and analyze those processes contributing to the adverse event and attempt to structure patient care to avoid future error. The challenge, and missed opportunity, has been to develop an approach to proactively and prospectively coordinate care in such a way that near misses and adverse events do not occur in the first place. Unfortunately, much of the factual information that must be incorporated into the decision-making process may not be known to members of the clinical team. Most clinical teams rely on physician documentation to identify clinical diagnoses and risk factors. Frequently, such documentation is ambiguous, non-specific, mis-stated, or simply absent. Further, there is recognition that due to the structural complexity and volume of data entered into the electronic medical record (EMR), few physicians actually review all information in the medical record. Dietary, physical therapy, nursing, emergency transport, and other records may indicate significant risk factors but go unnoticed by the care delivery team, generally, and the treating physician(s), specifically. Recognizing that physicians no longer function autonomously as the “captain of the ship,” hospitals are implementing clinical documentation management programs to fill in the quality and patient safety gap, recognizing the value of accurate clinical documentation for patient safety, quality, and reimbursement. A new member of the clinical team is now part of the safety and quality equation. Typically, this is an experienced RN, known as a Clinical Documentation Specialist (CDS), with additional training in documentation rules and regulations, definitional nuances, and opportunities for improving documentation. More and more, hospitals are incorporating a CDS in the clinical team. The CDS is a resource whose responsibility is to review all components of the medical record (paper or electronic) and bring to the attention of the treating physician(s) and clinical team undocumented or under-documented clinical conditions and a variety of clinically relevant risk factors. Risk factors may be identified from imaging studies, lab studies, clinical examination, vital signs, and other clinical parameters which may be “hidden” in the medical record. Clinical documentation improvement programs were initially focused on assuring Medicare-compliant documentation of principal diagnoses and comorbidities prior to discharge to improve the accuracy of hospital payment and quality scores. Increasingly hospitals are integrating CDSs (also called RN documentation specialists) as critical members of integrated quality care teams. The CDS may, in fact, be the only individual performing a comprehensive and concurrent review of the entire medical record.
Let me highlight how a CDS can make a significant impact on proactive, prospective patient safety and quality initiatives: Situation: An elderly patient presents to the emergency department following a fall with a displaced intertrochanteric fracture of the right hip. The treating orthopedic surgeon appropriately focuses on surgical options and the consulting internist treats the patient’s associated medical condition. The clinical team, utilizing an electronic medical record, assumes all clinical issues are being addressed.
Embedded in the EMR, and not reviewed by the orthopedic surgeon, is a notation by the dietician that the patient likely has severe protein calorie malnutrition. The clinical documentation specialist brings the condition to the attention of the orthopedic surgeon who orders appropriate nutritional support to enhance post-op wound healing (quality and patient safety). Additionally the physician documents “significant confusion,” a symptom. On review, the documentation specialist notes in the ED nursing notes a reference that the patient had been started on a new medication and was, according to the family, confused. The documentation specialist seeks clarification as to whether the patient was experiencing an episode of delirium (a syndrome) or more specifically toxic encephalopathy and whether, in the physician’s opinion, those conditions were present on admission.
Impact: By having a Clinical Documentation Specialist integrated into the clinical team, a hospital has achieved the following:- more accurate clinical documentation resulting in appropriate “severity capture,” allowing hospitals and physicians to get credit for the severity of illness of patients treated;
- enhanced communication between team members by identifying under-documented clinical conditions;
- identification of risk factors and conditions “present on admission” vs. “hospital acquired;”
- increased awareness of relevant clinical information that may go unidentified by team members not responsible for review of the entire medical record (particularly if electronic); and
- improved coordination between team members.?
Over the past decade many hospitals have implemented (to varying degrees of success) the electronic medical record, capturing vast amounts of information. Typically, nursing notes are now longer and much more comprehensive. The downside, however, is that physicians review such documentation less than they used to, in part due to time constraints in reviewing the multiple pages of documentation each nursing shift may generate. Under such time constraints, the likelihood of reviewing dietary, physical therapy and other sources of clinical information decreases. Clinical documentation specialists are well positioned to provide a much needed source of documentation review; “seeing the big picture,” if you will. One only needs to review “sentinel event” cases to identify failures of communication between care givers, or failure to identify risk factors at the clinical decision level, even though such indicators were present in the chart. It is clear that clinical documentation specialists have improved the accuracy of diagnosis coding and DRG assignment. However, over time, the CDS must be further integrated into the ongoing clinical process – inextricably linked with other providers, identifying clinical ambiguities, clinical predispositions, and risk and patient safety indicators, to further enhance the quality of clinical outcomes.
Paul Weygandt has been the vice president of physician services at J. A. Thomas & Associates in Smyrna, Georgia, since 2005. In that capacity, he has coordinated and delivered policy seminars to hospital and physicians leaders across the country. Weygandt began his career as an orthopedic surgeon. Adding expertise in law and business, Weygandt gained experience in hospital and health system management in roles as in-house legal counsel, system executive for managed care, and vice president for medical affairs. He may be contacted at
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