Utilization of a Concurrent Query Form to Improve Clinical Documentation in a VA Facility for Patients With Stroke or TIA

Caring for stroke patients diagnosed with acute ischemic stroke (AIS) and transient ischemic attack (TIA) at Veterans Health Administration (VHA) acute care hospitals is a very complex process that centers on accurate documentation. Inaccurate or missing documentation leads to patient safety issues, lower quality care, and inaccurate Veteran Equitable Resource Allocation (VERA) classification for reimbursement. This pilot project’s 3 problems of interest include improving provider response to clinical queries about documentation, capturing national metrics collected by the VHA, and accurately representing veterans in VERA classification. Based on a review of the literature available on patient treatment file (PTF) accuracy and clinical documentation improvement, the researcher used a three-pronged intervention for data collection and management plan. The data were abstracted from 97 (N = 97) AIS and TIA patient treatment files from calendar years 2015 to 2019, then compared with prospective data collected for a period of 3 months, and analyzed for statistical and clinical significance. The results of this pilot project included an increase in provider response to queries, captured metrics, and VERA classification of veterans that satisfies clinical documentation integrity according to VHA directives. Keywords: RN-led CDI program, clinical documentation improvement specialist, clinical and financial CDI outcomes, clinical documentation improvement model