Clinical Documentation: Telling the Story of Value-Based Services

 This text-based course is a transcript of the live seminar, “Clinical Documentation:  Telling the Story of Value-Based Services,” presented by Becky Sutherland Cornett, Ph.D., CHC.>> Becky Sutherland Cornett:  Let’s get started with our objectives for today’s session.  First we want to define “value” in health care.  Hopefully most of you have already seen articles or even blurbs in the newspaper that talk about the future of health care being “value” not “volume”.  Unfortunately most of us in health care are used to being paid for volume.  This includes hospitals, physicians, all therapists, and other ancillary professionals where the goal is to do as many procedures, visits, sessions, and inpatient services as possible.  This will be our culture challenge change.  We are also going to describe the components of the International Classification of Functioning, Disability, and Health (ICF) framework.    That framework has a common language of practice which I took from a couple of articles.  Also we are going to list the elements of results-focused clinical documentation.  Then we will discuss the importance of “telling the story” of value-based patient care which will be the only payable patient care in the future. What is Clinical Documentation?We know that clinical documentation is an essential component of clinical practice.  Unfortunately many people see this as an add-on and something they really do not want to do.  It is a struggle for many clinicians to realize that a very integral part of their job is documentation.  Why is this?  Documentation is integral because it is a tool to memorialize information about the patient and the work of the clinician.  One prominent physician advisor on documentation talks about it helping you to be recognized for your great work.  Documenting our patient care is our product/service.  This is what we have to show for what we are doing to and for patients to all the payors, regulators, and other members of the team.  It is a very important vehicle for communicating with other team members.  Even more than worrying about documenting for payment, we want to communicate with the other people, including the patient, who are participating in the patient’s, the client’s, or the student’s care.  This is not just applicable to health care.  Clinical documentation is a road map for assessing the practical value of our treatment which is the thrust of the presentation today.  Dr. Robert Douglas, who is a past president of ASHA and an ASHA honoree, said in a 1983 article and in many speeches, “How do we know and how do we show that what we do in therapy makes a difference?”  We need to ask ourselves this question every time we see a patient.  Another element of clinical documentation is that it is a requirement for payment.  We all know the famous sentence, “If it isn’t documented, it didn’t happen.”  This is not completely true, but that is the way payors view our services.  It is essential if we expect to be paid for something we are billing, we need to be documenting what we did.  It is a legal and regulatory document.  Medical records, other health records, and education records are used in court, and they are regularly audited.  As we know across the country, we are much more subject to audit than ever before by numerous government and commercial payors and regulators.  I will not be focusing on each and every element of documentation today.  I will discuss the ones myself and others have decided are the most important to show value of the services, but there are many more technicalities than I am presenting today.   The importance of this statement is that the key elements are really dictated by work setting and payor requirements.  To really manage ourselves, the clinician will want to set their own high standards for reflecting quality and professionalism.  It should not be that someone has to drag us kicking and screaming to the computer or paperwork.  It is essential to set standards for ourselves. There are two parts of documentation.   One is housekeeping which entails a lot of elements that I am not going to discuss today.  I will give you some references to places you can go for those.  The other part is the real substance of it.  Unfortunately, many times in the past, especially for Joint Commission and other accreditation bodies, we have somehow thought that if we showed that we did the housekeeping parts of the medical record by recording the demographics, having the right signatures, the right therapy credentials after our signature, formatting it correctly, making the right rules for corrections that our HIM departments tell us to do, that this would signify that we are doing a good job with documentation.  This really is just the housekeeping part and the beginning of it.  It is essential, but not the most important part.  The second part is substance of documentation.  This is telling the story of our excellent care, including our patient’s history, the assessment or evaluation of current status, our treatment plan, progress notes, and then what do we have to show for ourselves at the end with the discharge summary. Formulating a Plan of CareIn terms of formulating the plan of care, this new emphasis on value-based care and functional improvement is not new.  The Medicare program manuals have always stated that speech-language pathology treatment should result in significant practical improvement that occurs within a reasonable and generally predictable period of time.  That is the hallmark of the Medicare benefit policy manual.  Morever, treatment should consist of activities that reflect the need for the complex and sophisticated skills of a therapist.  I think too often payors and others think that what we are doing is a lot of repetitive workbook activities.  We will talk about this when I tell a story about my colleague and her parents.  What she observed the therapist doing in her home care situation versus what she would have known to do.  She had a lot more practical activities.  What are the things that speech-language pathologists are...