SHM Converge Scientific Abstract ePoster Gallery-Dynamic Auto-Documentation to Accurately Capture Patient Complexity and Mortality Risk

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This document describes a hospital quality-improvement project using a dynamic auto-documentation tool to improve comorbidity capture and mortality risk adjustment. Accurate documentation of comorbidities is important because under-capture can make patients appear less sick than they are, affecting severity of illness, risk of mortality, and metrics such as the Vizient Observed-to-Expected mortality ratio.<br /><br />The tool was embedded into hospitalist admission templates and used more than 40 Clinical Event Rules to scan structured patient data such as labs, vitals, EKG interpretations, nursing flowsheets, and dietitian assessments. When relevant conditions were detected, a pre-written assessment appeared in a SmartList for one-click insertion into the provider note. The system was implemented in May 2025.<br /><br />After implementation, documentation and billing of targeted comorbidities increased by 27% across the facility over the following 8 months. This improvement occurred without any increase in CDI query volume, suggesting that documentation became more complete without adding provider burden. Some conditions showed especially large gains, including debility, calcium disorder, hypovolemic shock, NSTEMI, cachexia, and cardiac arrhythmia.<br /><br />The main conclusion is that rule-based auto-documentation can meaningfully improve capture of clinically relevant comorbidities while integrating into existing workflows. The authors argue that this scalable approach may improve documentation accuracy, strengthen risk adjustment, and support more reliable quality metrics while reducing reliance on manual CDI efforts.

Asset Subtitle

Mahmoud Elsayed

Meta Tag

Author List Jose Joglar, Mahmoud Elsayed, Mandy Transou, Sandeep R. Das, Theo Sottero, Vivek Patel

Category Innovations

Concept Comorbidity Documentation

Concept Disease Severity

Concept Mortality Risk Adjustment

Concept Comorbidity Capture

Concept Inpatient Mortality Metrics

Distinguished Non-Finalist

Presenter Organization UT Southwestern

Presenting Author Mahmoud Elsayed

Track Technology in Hospital Medicine

Keywords

auto-documentation

comorbidity capture

mortality risk adjustment

hospital quality improvement

Clinical Event Rules

SmartList

documentation accuracy

CDI query volume

Vizient Observed-to-Expected mortality ratio

hospitalist admission templates

Comorbidity Documentation

Disease Severity

Mortality Risk Adjustment

Comorbidity Capture

Inpatient Mortality Metrics