SHM Converge Scientific Abstract ePoster Gallery-An Innovative Strategy to Improve Documentation of Atrial Fibrillation

Pdf Summary

This project addressed the importance of accurate diagnosis documentation for atrial fibrillation (AF), since specificity affects severity of illness, clinical outcomes data, risk stratification, quality metrics, and reimbursement. At Northwell Health, AF was identified as a high-yield target for clinical documentation improvement because there are five AF classifications, and all except paroxysmal AF count as a comorbid condition under CMS guidelines.<br /><br />The goal was to improve physician and advanced care provider documentation of AF specificity. The intervention included educational sessions for hospitalists, voluntary physicians, internal medicine residents, and advanced care providers on the five AF classifications. The team also built electronic medical record macros containing templated definitions of each AF type, making it easier for clinicians to select the most accurate diagnosis in their notes. In addition, weekly reminder emails were sent to the inpatient cardiology consult faculty, and random chart audits were used to provide direct feedback.<br /><br />After implementation in April 2021, documentation improved steadily. The average percentage of cases with a specified AF diagnosis increased from 54.1% in 2020 to 68.9% in 2021. Fulltime hospitalists and voluntary physicians, who represented about 60% of AF cases, were the main contributors to improvement, reaching an average compliance rate of 73% in 2021.<br /><br />Overall, the initiative showed that combining education, documentation tools, reminders, and audit-feedback can meaningfully improve AF documentation specificity.

Asset Subtitle

Esther Ahn

Meta Tag

Author List Aishwarya L. Nair, Benjamin Hirsh, Christine Catalan-Butvich, Esther Ahn

Category Innovations

Concept Atrial Fibrillation

Concept Documentation Specificity

Concept Disease Severity

Concept Risk Stratification

Concept Quality Metric

Distinguished Non-Finalist

Presenter Organization North Shore University Hospital, Northwell Health

Presenting Author Esther Ahn

Track Other

Keywords

atrial fibrillation

documentation improvement

diagnosis specificity

clinical documentation

hospitalists

advanced care providers

electronic medical record macros

CMS guidelines

chart audits

quality metrics

Atrial Fibrillation

Documentation Specificity

Disease Severity

Risk Stratification

Quality Metric