Most healthcare organizations are improving their documentation for ICD-10 and here are some crucial steps that should not be missed.

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Improving Your Clinical
Documentation Quality for ICD-10
As the implementation date of ICD-10 is approaching, healthcare practices are
required to improve their clinical documentation as soon as possible for adopting
the coding changes. Due to the higher level of specificity, the quality of
documentation is very important under the new coding system. For example, if you
are documenting fractures, focus should be given for fracture type, laterality,
episode of care and type of encounter since there are specific codes for all these
items. Here are some steps to be taken for improving the quality of your
documentation for ICD-10.
Gap Analysis
Clinical documentation may lack specificity due to the following reasons.
 Not documenting disease type
 Not documenting disease acuity
 Not documenting site specificity
 Not documenting disease stage
 Not documenting laterality
 Not documenting one or more details for a combination code

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Some healthcare organizations may struggle with all of these challenges while some
may need to address one or two. With a complete documentation gap analysis, you
can identify the challenges specific to your organization. A comprehensive cross-
section of cases, inpatient, ambulatory, outpatient, and physician practices can help
to identify areas for greater risk.
Standardization
Documentation quality teams within the organizations should collect all the
document types and other forms used throughout the patient care process in the
relevant organization. Then they should determine which of them are still relevant,
which need to be revised and which are obsolete. Based on this, they can derive a
standard documentation policy viable for ICD-10. Standardized policy includes the
standardization of content, structure and terminology. The quality team should find
out the areas where this kind of standardization would be appropriate. They should
also ensure that these standards are met and make improvements, if necessary
through reporting and analytics.
Training
Of course, the results of gap analysis and standardization will help organizations to
find an effective way to improve their documentation for ICD-10. However, it
requires efficient reference tools and training throughout the organization to

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interpret the results and make improvements accordingly. By providing enough
training to the staffs, healthcare organizations can build documentation habits and
technology that improve efficiency and standardization. This will also support
accuracy and completeness.
Technology Enhancement
Healthcare organizations should make sure that the technology used is appropriate
and configured optimally for the workflow and environment of a particular specialty.
For example, when it comes to documenting coma for ICD-10, it is required to
document the Glasgow Coma Scale (a neurological scale that captures a patient’s
conscious state for initial and subsequent assessment) while in the case of diabetes
it is required to document the type or etiology of diabetes, body system affected,
and any complications affecting that body system. Technology enhancement or
optimization include the designing of EHR fields and templates, checking how various
fields move from system to system via interfaces, processes for identifying errors
that migrate across systems, management of speech recognition profiles and so on.
Even if you are using electronic health records (EHRs) with speech recognition
system, the service of medical transcriptionists may be required to correct the errors
made and ensure the accuracy of documentation. Therefore, you should give proper
training to in-house transcriptionists as well or obtain the service of professional
transcription companies. In either case, ensure that your quality standards are met.
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