Physicians and documentation: Getting credit for great work

August 15th, 2018 / By L. Gordon Moore, MD

Why would an orthopedic surgeon develop expertise in documentation and coding? Eugene Christian, MD, Chief Medical Officer for St. Mary’s Bon Secours Hospital in Richmond Virginia describes his work on quality in this Inside Angle podcast

From his early clinical days as a Navy medical officer, Dr. Christian has been interested in improving process and outcomes. To inform the medical officer stepping into his role, he wrote what he knew about shipboard medical operations into a book that continues to be used today.

As an orthopedic surgeon at Carolinas Healthcare System (now Atrium Health), he took on a chief medical officer role that had inpatient quality as a major component. He discovered that clinical documentation insufficiency led to an inaccurate representation of the true illness burden of some patients, which in turn led to inaccuracies in the reported rates of quality indicators. By focusing on quality of care he found physicians were willing to work on improving documentation and Carolinas had sustained improvement in clinical indicators as a result.

Clinicians can have a conversation regarding a patient that includes a lot of shorthand: We may all understand “congestive heart failure” and if we need more detailed information we can delve into the subject. When we record information in a medical record we must convey specific and accurate information, as the medical record is not a vehicle for conversation but the representation of the clinical truth as best we can understand and describe for that patient.

Programs to improve documentation can help improve the quality of information shared about a patient, which in turn could improve the quality of care we deliver to that person. Dr. Christian’s focus on quality fit well with the medical staff and is translating well in his role as CMO for St. Mary’s Bon Secours Hospital in Richmond, VA.

L. Gordon Moore, MD, is Senior Medical Director, Clinical Strategy and Value-based Care for 3M Health Information Systems.