优化神经科学死亡率:改进文件记录的合作方法。

IF 2.3 Q3 CLINICAL NEUROLOGY
Neurology. Clinical practice Pub Date : 2024-08-01 Epub Date: 2024-05-23 DOI:10.1212/CPJ.0000000000200315
Yasmin Aghajan, Cheryl A Codner, Patricia Martin, Sandhya Prakash, Ronald Mendoza, Deborah L Jones, Bradley J Molyneaux
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引用次数: 0

摘要

背景和目标:死亡率指数是观察死亡率与预期死亡率的比率。准确、全面地记录患者的合并症和病情是决定神经科学预期死亡率的关键因素。在本研究中,我们重点审查了神经科学文档,因为优化死亡率指数可准确评估所提供的护理质量、提高服务线排名并影响报销:我们组建了一个由神经科医生和临床文档完整性(CDI)专家组成的跨专业团队,对一家三级学术医疗中心神经科学服务项目的所有死亡病例的临床文档进行了为期 9 个月的审查。我们确定了神经科学重症患者中常见的文档记录机会,以提高预期死亡率的准确性。使用 Vizient 公司提供的死亡率风险调整方法,我们比较了基线和审查后的预期死亡率:结果:我们在 9 个月内审查了 70 份死亡率病历。有 60% 的病历存在需要改进的地方。常见的漏报合并症包括吸入性肺炎、休克、脑病、血小板减少症、抗凝引起的出血性疾病和非创伤性蛛网膜下腔出血。在第一季度和最后一个季度之间,每位患者所确定的影响死亡率的诊断数从 4.3 增加到 7.8(p < 0.0001)。由于 CDI 专家在整个干预过程中增加了对神经科学特定诊断的捕捉,每位患者由医生确定的额外诊断从 1.0 减少到 0.3(p = 0.0037)。平均预期死亡率从基线的 0.33 显著上升至 0.42(p < 0.0001):讨论:医生与 CDI 专家之间的合作可通过识别神经科学患者文档中的常见缺陷来优化预期死亡率。神经内科医师的参与有利于 CDI 的开展,并为神经内科医师的临床文档教育奠定了框架。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Optimizing Neuroscience Mortality: A Collaborative Approach to Documentation Improvement.

Background and objectives: Mortality index is the ratio of observed-to-expected mortality. Accurate and thorough documentation of patient comorbidities and conditions is the key determinant of neuroscience expected mortality. In this study, we focused on reviewing neuroscience documentation, as optimizing mortality index provides accurate assessment of the quality of care provided, improves service-line rankings, and affects reimbursement.

Methods: We assembled an interprofessional team of a neurologist and clinical documentation integrity (CDI) specialists to review clinical documentation of all mortalities from the neuroscience service lines at a tertiary academic medical center over 9 months. We identified common documentation opportunities among high acuity neuroscience patients to improve accuracy of expected mortality. Using the mortality risk adjustment method from Vizient Inc., we compared baseline and postreview expected mortality.

Results: We reviewed 70 mortality charts over a 9-month period. Opportunities to improve documentation were present in 60%. Common underreported comorbidities included aspiration pneumonia, shock, encephalopathy, thrombocytopenia, hemorrhagic disorder due to anticoagulation, and nontraumatic subarachnoid hemorrhage. The number of diagnoses identified per patient that affected mortality increased between the first and last quarter from 4.3 to 7.8 (p < 0.0001). Physician-identified additional diagnoses per patient decreased from 1.0 to 0.3 (p = 0.0037), as CDI specialists had increased capture of neuroscience specific diagnoses throughout the intervention. The average expected mortality significantly increased from baseline 0.33 to 0.42 (p < 0.0001).

Discussion: Collaboration between physicians and CDI specialists optimizes expected mortality by identification of common gaps in documentation specific to neuroscience patients. Neurologist engagement is beneficial in CDI and lays the framework for clinical documentation education for neurology physicians.

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来源期刊
Neurology. Clinical practice
Neurology. Clinical practice CLINICAL NEUROLOGY-
CiteScore
4.00
自引率
0.00%
发文量
77
期刊介绍: Neurology® Genetics is an online open access journal publishing peer-reviewed reports in the field of neurogenetics. The journal publishes original articles in all areas of neurogenetics including rare and common genetic variations, genotype-phenotype correlations, outlier phenotypes as a result of mutations in known disease genes, and genetic variations with a putative link to diseases. Articles include studies reporting on genetic disease risk, pharmacogenomics, and results of gene-based clinical trials (viral, ASO, etc.). Genetically engineered model systems are not a primary focus of Neurology® Genetics, but studies using model systems for treatment trials, including well-powered studies reporting negative results, are welcome.
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