Impact of improved documentation on an academic neurosurgical practice

Journal of Neurosurgery
Omar ZalatimoMark Iantosca

Abstract

Accuracy in documenting clinical care is becoming increasingly important; it can greatly affect the success of a neurosurgery department. As patient outcomes are being more rigorously monitored, inaccurate documentation of patient variables may present a distorted picture of the severity of illness (SOI) of the patients and adversely affect observed versus expected mortality ratios and hospital reimbursement. Just as accuracy of coding is important for generating professional revenue, accuracy of documentation is important for generating technical revenue. The aim of this study was to evaluate the impact of an educational intervention on the documentation of patient comorbidities as well as its impact on quality metrics and hospital margin per case. All patients who were discharged from the Department of Neurosurgery of the Penn State Milton S. Hershey Medical Center between November 2009 and June 2012 were evaluated. An educational intervention to improve documentation was implemented and evaluated, and the next 16 months, starting in March 2011, were used for comparison with the previous 16 months in regard to All Patient Refined Diagnosis-Related Group (APR-DRG) weight, SOI, risk of mortality (ROM), case mix index (CMI), and...Continue Reading

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Citations

Mar 1, 2015·Journal of the American College of Surgeons·Richard C FrazeeHarry T Papaconstantinou
Jan 5, 2018·Neurosurgery·Aladine A ElsamadicyOren N Gottfried
Dec 27, 2019·Critical Care Medicine·Amy L Sanderson, Jeffrey P Burns
Aug 27, 2015·Neurosurgery·Timothy R SmithEdward R Laws
Mar 25, 2020·Critical Care Medicine·Amy L Sanderson, Jeffrey P Burns
Sep 20, 2020·Clinical Neurology and Neurosurgery·Christine ParkOren N Gottfried

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APR
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