Clinical Documentation’s positive effect on GMLOS

Accurate documentation assures the right reimbursement

The Salem Health Clinical Documentation Integrity team has eight clinical documentation specialists who perform concurrent reviews on inpatient medical records, as well as retrospective reviews on mortality charts. 

Why this is important:
Together, the efforts between CDI and providers ensure Salem Health is properly reimbursed for the care provided and reflects the severity of the patients we treat. 

The focus of each CDS chart review is to ensure clear medical provider documentation, which is supported by the clinical picture, and which is easily translated into coding language.

Without clear documentation, the CDS sends a query to the current attending provider; if this documentation is related to a procedure, the surgeon is queried. Queries can have many benefits. One benefit of improved documentation is an increase in the GMLOS (Geometric Length of Stay).

Examples of the impact provider documentation has on reimbursement and GMLOS:
Provider documentation from the same chart:

• Congestive Heart Failure (CHF), volume overload, weight loss, renal insufficiency = GMLOS 2.4 days
• Diastolic CHF, Lasix IV 40 mg BID, weight loss, Chronic Kidney Disease (CKD) stage III = GMLOS 3.3 days
• Acute-on-Chronic Diastolic Heart Failure, CKD III, severe malnutrition = GMLOS 4.1 days

Provider documentation from the same chart:

• UTI, Confusion, Hypotension, Fever, Elevated Lactic Acid, on 5L/NC, tachypneic = GMLOS 2.9 days
• UTI, Sepsis, AMS, acute respiratory distress = GMLOS 3.5 days
• Severe Sepsis with Associated Acute Metabolic Encephalopathy, Acute Hypoxic Respiratory Failure, UTI = GMLOS 4.8

As demonstrated in the examples above, accurate and complete documentation has a dramatic impact on the medical record – and therefore on adequate reimbursement. Thank you for your partnership in this important goal!