Nuance tools help Clinical Documentation Improvement (CDI) teams and physicians focus on capturing secondary diagnoses in children that will impact the reimbursement or severity of illness or risk of mortality and in turn, quality. Shannon emphasizes that while this is vital for reimbursement, it is also part of ensuring that the patient receives the care that they need.
3:45 “In the last few years, one of the biggest reasons for admission in pediatric hospitals has been acute bronchitis…If you think about acute bronchitis in an adult, that disease process is something that an adult is at home with...So we are looking at those other opportunities that made that child sick enough to be admitted into the hospital…acute respiratory failure or some time of aspiration…We are looking for other opportunities to just paint a better picture for the physician that shows why that seemingly simple diagnosis is at that level that they need to be admitted to the hospital...When you leave off the details, you open yourself up for misdiagnosis.”
Misdiagnosis is a huge problem in pediatrics and this can lead to litigation, or denial from insurance companies to cover important care. Digging further into the chart and providing these details only benefits the health and well-being of your patients and your organization.