2009 Faculty Researchers

Litofsky, Scott N., MD

Impact of Medical Record Documentation on Determining INdex of Severity of Illness

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Co-Investigator

Carol Hafney, MS, RN

Department

Surgery (Neurological Surgery)

Office Location

MC321

Phone #:

Office: (573) 882-4909
Fax: (573) 884-5184

Summary

AIM: To compare severity of illness documentation from three time periods – one during which no effort was made to appropriately document severity of illness versus one during which the medical record was redesigned to capture severity of illness data and education was actively provided versus one with the documentation tool after education was no longer actively provided – in order to determine if such documentation changes patient index of severity and leads to improvement of calculated hospital mortality rates

HYPOTHESIS: Appropriate documentation will better determine index of severity of illness and will improve in-patient mortality on a neurosurgical service

BACKGROUND: Mortality at University of Missouri Hospital and Clinics on the neurosurgery service has been worse than other comparable institutions. Insurance companies and other third-party payors may use this information to reduce payment to hospitals or to avoid contracting with hospitals. Review of the cases at UMHC suggests that patient management was appropriate, and patients who experienced a poor outcome where expected to do poorly. Review of the medical record suggests that severity of illness has not been adequately documented. Changes on general surgery services at other institutions (University of Tennessee) suggests that appropriate documentation leads to improved reimbursement and determination of mortality.

STUDY DESIGN: Time periods identified; 2003 – 2005, when severity of illness not considered and 2007 – present, when progress note changed to permit capture of co-morbidities by hospital coders, and 2008 after education provided. Compare cases in each time period for index of severity, co-morbidities identified per case, and hospital mortality. Statistical analysis of data.

STUDY PROCEDURE: Already IRB approved. Discuss with medical records personnel (Carol Hafney) and hospital personnel. Review charts of sequential admissions in each time period. Data to accrue – diagnosis, co-morbidites, patient age, patient sex, index of severity, discharge disposition (home, rehab, skilled nursing facility, death), length of stay. Statistical analysis.

ADMINISTRATION/ORGANIZATION: Single institution study. Will need assistance from hospital administration.