Objective: Accurate documentation is critical for patient care and hospital reimbursement. We sought to improve the accuracy of severity of illness (SOI) and risk of mortality (ROM) scores through implementation of documentation initiatives.
Methods: We performed a pre- versus post-implementation analysis to assess the impact of a documentation intervention bundle on calculated admission/discharge SOI/ROM scores on an inpatient gynecologic oncology service. Introduced in January 2017, the bundle included educational in-service, introduction of problem-based progress notes, a documentation tip ID badge and video, and weekly chart audits. Admission/discharge SOI/ROM scores (range 1-4) were obtained from hospital performance services. Demographics and 30-day mortality were collected from electronic medical records for all inpatients in historic (calendar year 2015) and intervention (2017) cohorts. Primary outcomes (discharge SOI/ROM) were modelled using ordinal and multinomial logistic regressions, controlling for confounders. 30-day observed/expected mortality ratios were reported for each cohort.
Results: 629 patients were included: 378 (60%) in 2015, 251 (40%) in 2017. Increased odds of having higher SOI score were observed in the intervention cohort for medical (OR = 2.22; 95% CI 1.38, 3.58) and surgical admissions (OR = 2.63; 95% CI 1.47, 4.40). Surgical (OR = 5.54; 95% CI 1.29, 23.96), but not medical (OR = 1.45; 95% CI 0.46, 4.57), admissions in the intervention cohort had higher odds of having the worst ROM score. Observed/expected mortality was 0.24 in the intervention compared to 0.37 in historic cohort (p = 0.58, NS).
Conclusion: An intervention bundle to improve physician documentation accuracy resulted in higher discharge SOI scores for medical and surgical admissions.
Keywords: Health assessment metrics; Health services; Optimal documentation; Quality improvement.
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