SHM Converge Scientific Abstract ePoster Gallery-Implementing a Standardized Diagnosis List to Enhance Clinical Documentation Accuracy

Pdf Summary

This poster describes an intervention to improve clinical documentation accuracy by embedding a standardized common diagnosis menu into an electronic note template at the University of Wisconsin Hospitals & Clinics. The menu was aligned with clinical billing codes and designed to help resident physicians choose more accurate, billable diagnoses during documentation.<br /><br />The study evaluated the tool in two ways: first, through a subjective survey of residents after implementation to assess usefulness and ease of use; and second, through objective clinical documentation metrics compared over time. These metrics included the number of diagnosis codes per discharge, complication/comorbidity (CC) or major complication/comorbidity (MCC) capture rates, Elixhauser Comorbidity counts, and the rate of clinical documentation integrity (CDI) queries. Outcomes from six months before implementation were compared with two months after implementation.<br /><br />Results showed improvement after the template was introduced. Average diagnosis codes per discharge increased from 19.7 to 22.5, average Elixhauser comorbidities rose from 3.9 to 4.3, CC/MCC capture rates improved slightly from 77% to 78%, and CDI query rates decreased from 36% to 32%. Resident feedback was also positive, indicating that the tool was useful and potentially valuable as a real-time educational aid.<br /><br />The authors conclude that a standardized diagnosis menu can improve documentation quality, increase capture of clinically relevant diagnoses, reduce administrative burden from CDI queries, and support resident education. They suggest future work should expand the number of billable codes included in the menu while maintaining resident involvement.

Asset Subtitle

Janki Mistry

Meta Tag

Author List Janki Mistry, Jennifer Passini MD, Jordan Kenik, Michael Dagenais RN, BSN, CCD, Sean O'Neill MD

Category Innovations

Concept Standardized Diagnosis List

Concept Documentation Accuracy

Concept Electronic Medical Record Template

Concept Diagnosis Code

Concept CC/MCC

Distinguished Non-Finalist

Presenter Organization University of Wisconsin Hospitals & Clinics

Presenting Author Janki Mistry

Track Quality Improvement

Keywords

clinical documentation

diagnosis menu

electronic note template

billing codes

resident physicians

documentation accuracy

CDI queries

Elixhauser comorbidity

CC/MCC capture

University of Wisconsin Hospitals

Standardized Diagnosis List

Documentation Accuracy

Electronic Medical Record Template

Diagnosis Code

CC/MCC