title: 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.
authors.affiliation: Division of General Internal Medicine, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA. bspellberg@labiomed.org
authors.forename: Brad
authors.initials: B
authors.lastname: Spellberg
authors.forename: Darrell
authors.initials: D
authors.lastname: Harrington
authors.forename: Susan
authors.initials: S
authors.lastname: Black
authors.forename: Darryl
authors.initials: D
authors.lastname: Sue
authors.forename: William
authors.initials: W
authors.lastname: Stringer
authors.forename: Mallory
authors.initials: M
authors.lastname: Witt
mesh_terms: D000046:Academic Medical Centers; D002140:California; D014487:Centers for Medicare and Medicaid Services, U.S.; D059019:Clinical Coding / Q000592:standards; D015897:Comorbidity; D003479:Curriculum; D003953:Diagnosis-Related Groups; D004282:Documentation / Q000592:standards*; D004503:Education, Medical, Graduate / Q000379:methods; D017052:Hospital Mortality; D006801:Humans; D007388:Internal Medicine / Q000193:education*; D008499:Medical Records / Q000592:standards*; D058996:Quality Improvement; D014481:United States
keywords: Case mix index; Centers for Medicare and Medicaid Services; Coding; Complication code; Documentation; Graduate medical education; Mortality index; Resident education