Capturing the Diagnosis: An Internal Medicine Education Program to Improve Documentation

Abstract Background Specific and accurate documentation of patient diagnoses and comorbidities in the medical record is critical to drive quality improvement and to ensure accuracy of publicly reported data. Unfortunately, inpatient documentation is taught to internal medicine trainees and practitioners sporadically, if at all. At Harbor-UCLA Medical Center, a public, tertiary care, academic medical center, we implemented an educational program to enhance documentation of diagnoses and comorbidities by internal medicine resident and attending physicians. Methods The program consisted of a series of lectures and the creation of a pocket card. These were designed to guide providers in accurate documentation of common diagnoses that group to different levels of disease severity, achieved by capturing Centers for Medicare and Medicaid Services complication codes and major complication codes. We started the educational program in January 2010 and used a pre-post design to compare outcomes. The program's impact on complication codes and major complication codes capture rates, mortality index, and case mix index was evaluated using the University Health Consortium database. Results The median quarterly complication codes and major complication codes capture rate for inpatients on the internal medicine service was 42% before the intervention versus 48% after ( P = .003). Observed mortality did not change but expected mortality increased, resulting in a 30% decline in median quarterly mortality index ( P = .001). The median quarterly case mix index increased from 1.27 to 1.36 ( P = .004). Conclusions Thus, implementation of an internal medicine documentation curriculum improved accuracy in documenting diagnoses and comorbidities, resulting in improved capture of complication codes.