Clinical Casemix Handbook 2012-2014 Version 3.0

Transcription

Performance Activity and Quality Division
Clinical Casemix
Handbook
2012-2014
Version 3.0
improving care managing resources delivering quality
© Department of Health, State of Western Australia (2012).
Copyright to this material produced by the Western Australian Department
of Health belongs to the State of Western Australia, under the provisions of
the Copyright Act 1968 (Commonwealth Australia). Apart from any fair dealing
for personal, academic, research or non-commercial use, no part may be
reproduced without written permission of the Performance Activity and Quality
Division, Department of Health Western Australia. The Department of Health
is under no obligation to grant this permission. Please acknowledge the
Department of Health Western Australia when reproducing or quoting material
from this source.
Important Disclaimer:
All information and content in this Material is provided in good faith by the
Department of Health Western Australia, and is based on sources believed
to be reliable and accurate at the time of development. The State of Western
Australia, the Department of Health Western Australia, and their respective
officers, employees and agents, do not accept legal liability or responsibility
for the Material, or any consequences arising from its use.
To request permission to reproduce these materials, please contact the
Performance Activity and Quality Division at [email protected]
These materials are regularly updated. For the latest version go to the ABF/ABM
intranet site at http://activity or the internet site at www.health.wa.gov.au/activity
ISBN: 978-978-192-184-1
Clinical Casemix Handbook 2012-2014
Version 3.0
Contents
Foreword
3
Acknowledgements
4
1.Introduction
5
1.1 Why is this important?
1.2 The documentation process from patient admission to end data
2. Casemix, coding and DRGs
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8 2.9
What is casemix?
What is clinical coding?
What are complication and co-morbidity codes (CCs)?
What are diagnosis related groups (DRGs)?
DRG structure
How is a DRG assigned?
Clinical information audit program
Costing and funding of health care
The ABF operating model
3. Clinical documentation
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6
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7
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10
10
10
13
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15
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3.1 Clinical incidents and adverse events
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4.
Clinical handover
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5. Completing the discharge summary
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5.1 Guidelines for completing a good discharge summary
5.1.1 Content
5.1.2Clarity
5.1.3Sequencing
5.2 Requirements of the discharge summary
5.2.1 Principal diagnoses
5.2.2 Past history
5.2.3 Presenting problem
5.2.4 Additional diagnoses
5.2.5Operations/procedures
5.2.6 Relevant investigation result
5.2.7 Treatment and progress
5.2.8
Medication
5.2.9 Future plan of management
6. Sample discharge summary
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Clinical case studies
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Common complications and co-morbidities
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Appendixes
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Appendix A AR-DRG major diagnostic categories
Appendix B The AR-DRG classification system
B.1Structure
B.2 Broad group
B.3 Adjacent DRG
B.4 Split indicator
B.5 AR-DRG treatment of severity
B.6 Example 1: DRG assignment
B.7 Example 2: DRG assignment
B.8 Impact of CCs on cost signature
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Appendix C
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Glossary
References
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Foreword
Clinical documentation plays an important role in ensuring the quality and safety
of patient care as well as contributing to medical research and the delivery of
evidence based care.
Producing accurate clinical documentation which captures consistent and
transparent information about how a patient has been cared for is a fundamental
aspect of a clinician’s role.
Activity Based Funding and Management (ABF/ABM) was introduced in 2010
as the new way of managing the health service in WA. Ultimately ABF/ABM will
ensure health resources flow to where they are most needed.
ABF/ABM relies on timely and accurate information about patients and their
care to ensure the ongoing delivery of safe high quality care to the community
of WA. This information will enable the community, clinicians, public servants
and Government to make informed decisions about how and where we deliver
healthcare across WA.
Working together, each of us has a role to play in delivering excellence
in healthcare to the people of Western Australia.
This booklet has been developed to support all clinicians in that aspect
of their work.
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Acknowledgements
This document was developed by the Activity Based Funding and Management
Team within the Performance Activity and Quality Division of Department of
Health. The team would like to thank staff across WA Health for their contributions.
In particular, the team extends a thank you to colleagues from Health Services,
Health Networks and the Postgraduate Medical Council of Western Australia.
We also acknowledge the authors of the Alfred Casemix Clinical Handbook 10th
Edition (2009 – 2010)(1), and the National Centre for Classification in Health –
University of Sydney (2003). Good Clinical Documentation Guide, on which this
handbook was based.
Finally, the purpose of activity based health improvement reform is to improve
health services and hospitals for WA patients, communities and populations.
We acknowledge and thank them as our partners in improvement.
Activity Based Funding and Management Team
September 2012
Intranet: http://activity
Internet: www.health.wa.gov.au/activity
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1. Introduction
1.1 Why is this important?
The quality of the information in a patient’s medical record is a key element of the
safety and quality of the care we deliver. Accurate and timely health information
is vital to safe and effective handover of care between healthcare professionals.
Good documentation ensures that all clinical staff caring for patients in present
or future episodes has access to the records they need to optimally care for the
patient. Problems with communication, and in particular documentation, are widely
recognised as major contributing factors in the occurrence of sentinel events.(10)
Casemix and Diagnosis Related Groups (DRGs) are used to collect, classify,
code, count and cost the diverse range of care that is provided in our hospitals.
This facilitates organising the health system as efficiently and effectively as
possible so that we can provide safe high quality care to the WA community.
It is important for clinicians to understand this because:
It impacts on how services are funded – we need an accurate picture of the
services we provide so we can ensure services are funded properly.
It impacts on how services are delivered and the workforce required to
deliver them – future plans for clinical services are based on information
about the current and future health needs of the community.
The handbook outlines the clinical coding process, from its use of diagnoses and
complications or co-morbidities to determine care and complexity levels, to the
final assignment of DRGs. It shows how the DRG is then used to drive the Activity
Based Funding and Management approach.
One of the key components of this resource is highlighting the importance of
accurately documenting clinical information in the patient’s medical record and
producing an accurate and timely discharge summary.
The information you create as part of a patient’s medical record is used
in many different ways.
Health information should be legible, timely and accurate.
It is essential for safe and effective communication between health
professionals.
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1.2 The documentation process from patient admission
to end data
Documentation related to
episode of care
Discharge summary
completion
Assignment of ICD-10-AM
codes for diseases and
procedures
Abstraction of information
from the clinical record
Assignment of DRGs
National Centre for Classification in Health. 2003(2)
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Casemix,
coding and
DRGs
Casemix, coding
and DRGs
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2. Casemix, coding and DRGs
This section provides some background to explain how the information in the
medical record is used in determining the activity and funding levels within a
hospital or health service. It covers casemix classification systems, clinical coding,
costing and funding.
2.1 What is casemix?
Casemix refers to the range and types of patients (the mix of cases) treated by
a hospital or other health service. It provides a way of describing and comparing
hospitals and other services, thereby assisting in planning and management of a
health care system.
Casemix classifications put patients into clinically meaningful groups that use
similar health care resources. By doing so, the clinical activity, quality and costefficiency of different hospitals can be compared.
However, the introduction of an activity based funding (ABF) framework in WA
is not just about hospital casemix. It can include community care and/or chronic
disease programs, preventive health programs, shared maternity care, subacute
and step down care, living well when older, education, training, research and other
services.
Casemix data is used for many purposes, including; clinical research,
funding and financial management, identifying epidemiological patterns
and disease trends, reviewing resource consumption, workforce and
facilities planning, monitoring quality of care, and making comparisons
between facilities, areas and states.
2.2 What is clinical coding?
Coding involves reviewing and extracting information from the medical record
based on documented clinical information and translating this clinical information
into code. Information coded includes:
principal diagnosis
other primary diagnoses
co-morbidities relevant to the admission
complications
procedures performed (both therapeutic and diagnostic).
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Through accurate documentation, the clinical coder can translate information
into a series of alphanumerical and/or numerical codes to reflect the complete
clinical picture.
Clinical coders use the International Statistical Classification of Diseases and
Related Health Problems, 10th Revision, Australian Modification (ICD –10-AM),
7th Edition – 1 July 2010.
ICD-10-AM consists of:
A disease classification based on the World Health Organisation’s
publication ICD-10 with modifications to ensure a current and appropriate
classification for Australian clinical practice.
An Australian procedure classification, the Australian Classification of Health
Interventions (ACHI), which is based on the Medicare Benefits Schedule
(MBS).
Australian Coding Standards (ACS); a set of specific rules, which aim
to standardise clinical coding practice nationally, covering both general
principles and specific specialty issues(3).
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2.3 What are complication and co-morbidity codes (CCs)?
Complication and co-morbidity (CC) codes are additional diagnoses that are likely
to result in significantly greater resource consumption during an inpatient episode.
Each of these additional diagnoses is assigned a complication and
co-morbidity Level (CCL) and from these, a patient care complexity Level
(PCCL) is then calculated and assigned for every record. The PCCL is a measure
of the cumulative effect of a patient’s complications and co-morbidities. Adjacent
DRGs have differing levels of resource consumption and are split on the basis
of the PCCL, malignancy, same day status, mental health status and mode of
separation.
A complication is a condition not present on admission which arises during the
patient stay, or is the result of a procedure or treatment during the stay.
Examples are:
embolism
drug reaction
urinary tract infection (UTI)
post-operative infections.
A co-morbidity is a condition that exists at the time of admission, which affects
patients care in terms of requiring:
therapeutic treatment
diagnostic procedures
increased clinical care and/or monitoring.
One or more of the above factors will generally result in an extended length
of stay. The inclusion or exclusion of CCs has a dramatic impact on the DRG
assigned and therefore an appropriate remuneration for the resources used,
especially under an activity based funding framework. It is crucial that any
complications of treatment or surgery, and any relevant additional diagnoses are
documented, to ensure accurate DRG assignment with subsequent appropriate
funding to the health service.
For more detailed information refer to Appendix A: Common complications and
co-morbidities.
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2.4 What are diagnosis related groups (DRGs)?
Diagnosis Related Groups (DRGs) are commonly used as the basis of an
inpatient classification system. Australian Refined Diagnosis Related Groups
(AR-DRGs) are refined for use in Australia and provide a clinically meaningful
way of relating types of patients treated in a hospital to the resources required
to treat them. AR-DRGs use information in the patient’s hospital record such as
diagnoses, procedures, co-morbidities, complications, and age to classify the
patient.
Relevant diagnoses and procedures are coded for each admitted patient episode
and the combination of codes for each episode guide its assignment to a DRG
by way of using DRG grouper software.
2.5 DRG structure
This indicates the
Major Diagnostic
Category (MDC)
to which the DRG
belongs
There are
23 MDCs
E 6 5 A
This indicates the partition to
which the DRG belongs
01–39 surgical
40–59 other
60–99 medical
Split indicator
ranks the resource
consumption of a DRG
A highest consumption
B second highest
C third highest
D fourth highest
Z no split
Example: DRG E65A – Chronic Obstructive Airways Disease with Catastrophic CC
E: MDC – respiratory System, 65: medical, A: split ranking it as highest resource
within the DRG65 group.
2.6 How is a DRG assigned?
Clinical coders assign ICD-10-AM codes to the episode of care which are entered
onto the hospital’s patient administration system. The DRG grouper (software)
generates a DRG for each inpatient episode, based on the provided codes and
other patient information. Diagram 2 displays the DRG classification process.
AR-DRG version 6 incorporates 698 AR-DRGs, most of which are organised into
23 Major Diagnostic Categories (MDCs) – generally based on body systems
(see Appendix A). Each MDC contains three partitions – surgical, other and
medical DRGs. The presence or absence of operating room and non-operating
room procedures is generally responsible for the assignment of a record to one
or the other of these partitions. For more detailed information refer to the section
Common complications and co-morbidities.
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For some MDCs and DRGs there are variables, other than ICD-10-AM codes,
which may affect DRG assignment. These variables are:
patient age and sex
length of stay
same day status
admission weight for infants aged <365 days
mental health legal status
mode of separation.
Note: Ethnicity and/or Indigenous status have no bearing on DRG assignment.
Prior to allocation to a MDC, pre-MDC processing occurs, which identifies and
assigns very high cost DRGs for the following conditions:
age <28 days
age <1 year with an admission weight <2,500g
principal or secondary diagnosis of HIV or related condition
liver, heart, lung, bone marrow or multiple organ transplant
significant trauma >1 body site
ECMO without cardiac surgery
tracheostomy/MV > 95 hours.
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Diagram 2: Typical DRG classification process(2)
Diagnoses and procedures coded using ICD-10-AM
Identify principal diagnosis
Assigned to a Major Diagnostic Category (MDC) (23 groups)
Exceptions
•Age <28 days
•Age <1 year with an admission weight <2,500g
•Principal or secondary diagnosis of HIV or related
condition
•Liver, heart, lung, bone marrow or multiple organ
transplant
•Significant trauma >1 body site
ECMO without cardiac surgery
•Tracheostomy/MV > 95 hours
Assigned to
Pre-MDC DRG
Check for significant OR procedure
NO
Check for non-OR procedure
NO
YES
YES
MEDICAL PARTITION
OTHER PARTITION
SURGICAL PARTITION
Grouped according to
principal diagnosis,
e.g. neoplasm, specific
conditions, symptoms,
other
Grouped according
to principal diagnosis
and non-OR
procedure
Grouped according
to type of surgery,
e.g. major, minor,
other, unrelated to
principal diagnosis
Checked for:
CC, age, other split
Checked for:
Checked for:
DRG assigned
DRG assigned
DRG assigned
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2.7 Clinical information audit program
The Performance Activity and Quality Division regularly conduct clinical
information audits of public hospital inpatient episodes. The aim of these audits is
to examine the inpatient data, with emphasis on accuracy of ICD-10 coding and
AR-DRG assignment. Episodes randomly selected for audit are re-coded from the
source data at hospital level through review of the discharge summaries and the
medical records.
These audits provide an opportunity to enhance communication between
clinicians and clinical coders, raising any anomalies in the ICD-10-AM
classification, AR-DRG grouper or relative weights assigned to DRGs. These
anomalies may be reported to the relevant State and Commonwealth bodies for
consideration in the revision processes for future versions of the classification
and/or grouper software. The audits are conducted by a small team of nationally
accredited auditors from the Business and Financial Modelling Directorate.
Audits allow us to develop a number of guidelines on how to accurately document
diagnoses and procedures to ensure that the hospital is adequately reimbursed
for the patients treated.
Accuracy of coded patient information can improve with:
Greater understanding by clinical coders of disease processes, interventional
techniques, and clinical practice relevant to their particular hospital.
Enhanced understanding of the hospital’s casemix and activity based
funding profile.
Greater understanding by clinicians of what coders require from discharge
summaries and inpatient notes, in order to comprehensively code a patient’s
episode.
A better understanding by clinicians, coders and Health Information
Managers, of the DRG allocation process and factors influencing accurate
DRG assignment.
2.8 Costing and funding of health care
The DRG cost is determined through patient level clinical costing which is
undertaken regularly at Health Service level by dedicated costing staff. Patient
level costing is the output of a modelling process by which costs are allocated
to individual episodes of care. For example when a patient has a CT scan at the
imaging department, the cost of that scan is matched to that patient episode.
The process ensures that the Department of Health submits patient costed data to
the Federal Government’s National Hospital Cost Data Collection (NHCDC) and
provides local data for the WA activity based operating model development and
implementation.
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WA public hospitals are funded based on the level and type of activity they are
expected to provide. Inpatient activity is classified into DRGs, measured as
weighted separations, which are then used for funding purposes.
Each DRG has a weight which is a measure of the cost of treatment of the
average inpatient in the DRG. This weight reflects the expected resource intensity
of the cases that fall into that DRG, relative to all other DRGs.
These weights are called “Weighted Activity Units” (WAUs). These are developed
for each category of services which are funded on an activity basis. These include
inpatient, outpatient and emergency department activity.
The weighted activity unit (WAU) of a knee replacement admission (4.1442)
will have a greater weight than that of a dialysis admission (0.1324) due to
the greater complexity and costs involved.
The ABF allocation for health services is determined by multiplying the price by
the volume of activity, expressed in weighted activity units (WAU). The WAU is
the national weighted activity unit (NWAU) as determined by the Independent
Hospital Pricing Authority (IHPA) , based on national classifications for inpatient,
emergency department and hospital based outpatient services.(4)
Table 1, below demonstrates how complexity of care, captured through clinical
coding, is reimbursed at a higher rate to reflect the higher costs which are incurred
in delivering that care. This complexity is identified in the medical record through
the documenting of diagnoses, particularly complications and co-morbidities.
Table 1: Example of payment for DRG I12 Infection/Inflammation of Bone and
Joint with Miscellaneous Musculoskeletal procedure
DRG
Complexity
I12A
with catastrophic
co-morbidity and/or
complication
LBP
HBP
WAU
Price
Payment
8
74
7.6248
$5,135
$39,153
I12B
with severe or moderate
co-morbidity and/or
complication
4
42
4.4288
$5,135
$22,742
I12C
without co-morbidity and/or
complication
2
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2.5905
$5,135
$13,302
LBP: low boundary point
HBP: high boundary point
WAU: weighted activity unit
Calculated using Independent Hospital Pricing Authority (11) acute admitted patients AR-DRG v 6.x price
weights and Health Activity Purchasing Intentions 2012-2013 (4) state efficient price of $5135
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2.9 The ABF operating model
A patient’s Length of Stay is an important factor in the calculation of the hospital’s
resource use. In the ABF operating model an average length of stay (ALOS)
is determined for each DRG; along with a low-boundary point (one third of the
ALOS) and a high boundary point (three times the ALOS). These length of stay
boundaries have been determined to enable exceptional episodes to be identified
and funded appropriately.
In Diagram 3 the funding (red line) illustrates how it is likely that the costs of
providing care to long stay patients will exceed the payment the hospital receives.
The average cost per episode (the green line) illustrates the direct link between
the length of a patient’s stay in hospital and the costs of providing that care:
A reduction in the length of stay for inlier episodes improves the efficiency
of a hospital.
The funding model for core or central activity has built in incentives to
encourage early discharge where appropriate.
If a patient is discharged before the average length of stay the health service
keeps the credit for the full episode payment.
Episodes with above average length of stay will tend to be more costly than
the average patient within that DRG.
Diagram 3: Inpatient Cost Modelling: DRG Inpatient cost signature(4)
2012-2013 state efficient price of $513
Inlier/central episodes have nights of stay within or on the low and high
boundary points and all inlier/central episodes within each DRG are funded
at the same rate
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3. Clinical documentation
The primary benefit of good documentation is to support the provision of high
quality and safe patient care. It ensures that all clinical staff caring for patients in
present or future episodes have access to the records they need to optimally care
for the patient.(2)
Good clinical documentation also ensures reliable information is available for
other purposes such as research, planning, and in providing the information
required to produce quality coded clinical data to be used in activity based
funding.
It is therefore in the best interest of every patient and provider that the medical
record contains complete and accurate documentation of each episode of care.
Ensuring that clinical information is documented in the medical record is
crucial for safe and high quality patient care. It also facilitates coding and
accurate DRG assignment and subsequent appropriate funding to the
health service.
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The following are general guidelines for clinical documentation.
You should also refer to your health service policies for details any local
requirements. Please ensure:
documentation is complete
daily progress notes or care plans are documented
a discharge summary is completed at the time of discharge.
Where clinically relevant, the following information should be included in every
health record:
history – presenting problem; history of presenting problem; other past
history; personal history; and family history
examination
diagnoses
management
discharge planning
procedures
anaesthetic record
progress notes
discharge summary
outpatient and Emergency Department notes.
Use commonly accepted terminology and abbreviations
Spell out abbreviations when there could be confusion as to its meaning, for
example; PE – pulmonary embolism or pleural effusion?
Avoid the use of eponyms unless its use is clear or commonly accepted, for
example; Jaboulay procedure – gastroenterostomy or repair of hydrocele?
Avoid the use of observational descriptions versus defined diagnostic terms, for
example; Operation report states “Turbid Fluid in abdominal cavity”. The surgeon
is generally referring to “infective peritonitis”. Please document ‘peritonitis’ as this
a recognised coding term and its inclusion impacts on the DRG assignment.
Another example is type 1 or type 2 respiratory failure. This is another widely
used clinical term. However, the only terms in ICD-10-AM are acute, chronic or
unspecified respiratory failure. These terms (type 1 or type 2) will be coded to
‘unspecified respiratory failure’ which has no complexity level, whereas “acute”
and “chronic” have significant complexity levels as additional diagnoses, impacting
on the DRG classification.
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Timeliness of documentation is important
The accuracy of clinical documentation is improved if the information is recorded
as soon as possible. Ensuring the timely completion of discharge summaries also
improves communication with other healthcare practitioners.
Write legibly
Communication with other healthcare practitioners and clinical coders is improved
when documentation is legible.
Work closely with clinical coders
The coder and clinician working together will improve the standard of both coding
and documentation.
“Improving documentation it is about making the patient’s journey through
the health care system safer and smoother – it is not about making the coder’s
life easier. ”
Dr Ted Stewart-Wynne, Director Medical Services, Royal Perth Hospital
3.1 Clinical incidents and adverse events
Preventable adverse events continue to occur in all healthcare systems in
the world, including WA Health. These cause significant distress to patients,
carers and their families, and add unnecessary cost to the taxpayer. Modelling
undertaken by WA Health suggests that the annual cost attributable to preventable
adverse events in WA is as high as $170 million(10).
All adverse events should be factually documented in the patient’s medical record
and discharge summary thus ensuring accurate coding and inclusion in DRG
classification.
Clinical incidents, adverse events and sentinel events are to be reported and
managed in accordance with the current Clinical Incident Management Policy(6).
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Clinician and coder collaboration delivers quality
Respiratory Medicine – Sir Charles Gairdner Hospital 2012
The Respiratory Medicine team at Sir Charles Gairdner Hospital recognised
the importance of reporting correct activity levels in an ABF/M environment.
They approached the Clinical Coding Coordinator to enquire into the accuracy
of coding and whether the effort of their clinical input would be worthwhile. After
reviewing the medical record, if the clinical coders had any concerns and felt
they were not being provided with the full clinical picture to enable the case to
be coded correctly, they agreed to pass them on for clinical review.
Approximately 20% of respiratory cases were reviewed. Of the cases that
required amending, subsequent DRG reclassification equated to a 30%
increase in expected revenue. Not only did this highlight the need to educate
clinical staff in the importance of accurate documentation, it also highlighted
that clinicians were unlikely to attain the skills and expertise of the clinical
coders. By working together, coders and clinicians have created a valuable
partnership and subsequent plans have been made for them to meet weekly
to review selected cases.
A similar process was undertaken within a surgical unit at SCGH with almost
identical findings and outcome. An unexpected outcome from this process
was the discovery that the electronic discharge summary software sorted
the diagnoses into alphabetical order regardless of the order they had been
entered. For example: the principal diagnosis was not appearing first with
other diagnosis following in order of importance. This was not only hindering
the coding process but also the quality of the discharge summary information
provided to ongoing care providers. This issue has since been addressed and
the Principal Diagnosis is now clearly separated from other diagnoses.
“Working with the team of coders
not only demonstrably improves the
accuracy of capturing clinical activity
levels, but also provides useful insights
into the quality of documentation by
junior staff, as well as an appreciation of
how attention to details in describing the
individual aspects of an episode of care
is vital to defining the bigger picture of
the overall admission. We also found
that experienced coders can reliably
identify cases which require additional
clinical input as opposed to needing
clinicians to double check every case”.
Clinical Coding Coordinator,
Sharon Linton and Dr W. Chin
Dr. Weng Chin, Respiratory Physician,
SCGH
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4. Clinical handover
Clinical handover is the transfer of professional responsibility and accountability
for some or all aspects of care for a patient, or group of patients, to another
person or professional group on a temporary or permanent basis(5). “Clinical
handover is a high risk area for patient safety” and a priority area for patient safety
improvement for the WA health system(9).
Good clinical handover is essential for protecting patient safety
Clinical handovers include, but are not limited to:
escalation of the deteriorating patient
shift-to-shift handover
intra-hospital transfer
transfer from one inpatient facility to another
discharge from an inpatient facility.
Two important evidence-based principles for best practice in handover are
emerging: face-to-face communication and documentation. Problems with
communication, and in particular documentation, are widely recognised as major
contributing factors in the occurrence of sentinel events.(10)
The aim of clinical handover is to achieve the effective communication of
high-quality, relevant clinical information at any time when responsibility and
accountability for patient care is transferred.
Standardisation of handover, as part of a comprehensive, system-wide strategy,
aids effective, concise and inclusive communication in all clinical situations and
contributes to improved patient safety(9). It is recommended that clinical handovers
initiated by WA Health staff:
are supported by education
are structured according to the iSoBAR(8) tool (see back page)
use pre-prepared documentation
are conducted in an appropriate environment (i.e. minimise interruptions,
access to patient information), using an appropriate modality (i.e. face to
face, telephone, written).
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Completing the discharge
summary
Completing
the discharge
summary
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5. Completing the discharge summary
The discharge summary may be the only form of communication that
accompanies the patient to the next setting of care. Delayed or inaccurate
communication between hospital-based and primary care physicians at hospital
discharge may negatively affect continuity of care and contribute to adverse
events.
The hospital discharge summary is the primary document communicating
a patient’s care plan to the post-hospital care team.
The diagnoses and procedures documented on the discharge summary should
accurately describe why the patient was admitted to hospital and how they were
treated.
As well as clinician to clinician communication, this forms the basis for assignment
of codes by the clinical coder, along with reference to all other documentation
pertaining to the admission.
This section outlines the importance of ensuring the discharge summary is well
structured, as well as accurate and timely.
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5.1 Guidelines for completing a good discharge summary
This section highlights the key elements to a well structured discharge summary:
Content: information should be accurate and comprehensive
Clarity: information should be clear and concise
Sequencing: information should be structured in a logical and helpful way
to ease communication.
5.1.1 Content
Ensure that the patient’s conditions and diagnoses are documented and
substantiated throughout the medical record, not just in the discharge
summary i.e. in progress notes, investigation results. Clinical coders require
documented evidence of a particular condition being treated during the
episode of care before assigning the corresponding code.
Note any complications that may have arisen and their cause if known.
Document any clinical incident, adverse event or sentinel event that may
have arisen during the patient’s stay in hospital. (Note that only facts should
be documented.). Document cause of death e.g. respiratory failure, renal
failure.
Document all diagnostic and therapeutic interventions, described as
specifically as possible.
Include past medical/surgical history and future progress/management.
5.1.2 Clarity
Itemise each diagnosis which should be coded. Diagnoses which need
to be abstracted from long descriptive paragraphs could be missed.
Ensure that diagnoses documented in the progress notes are also
documented in the discharge summary. If this is not done, the correct
diagnosis may be missed by clinical coders.
Example 1
“Tissue removed at debridement, post-hemiarthroplasty, grew pseudomonas
and enterococcus”. A diagnosis of infection was intended. However, the term
“infection” was not listed and the appropriate code was not assigned.
Make references to results pending. The clinical coding may require updating
when all results are finally reviewed.
Avoid non-standardised terminology e.g. “dyscopia”.
Specify how accidents happen and where they occur e.g. slipped on
pathway at home, fall from ladder at work.
Medical abbreviations, acronyms and eponyms may be used, as long as
they have standard well-recognised meanings. Any ambiguity should be
avoided.
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Example 2
The abbreviation “PE” was used throughout the medical record and on the
discharge summary and was coded as pulmonary embolus. The clinician later
confirmed the intended diagnosis was pericardial effusion.
Be as specific as possible in diagnosis documentation e.g. whether
a condition is acute or chronic or both: whether liver disease is known
to be fibrosis, cirrhosis, etc.
Clinical coders will not be able to judge the clinical significance of laboratory
or histopathology results, nor are they required to make these judgements.
Any such findings, where significant, need to be included in an itemised
diagnosis e.g. UTI – E coli.
Underlining abnormal biochemistry (e.g. K, Na+), in the progress notes, will
not guarantee that the condition is coded. The diagnoses should be itemised
on the discharge summary (e.g. hypokalaemia, hyponatremia) if deemed
clinically significant.
Specify, if known, the duration or approximate duration of any loss
of consciousness associated with head injury.
5.1.3 Sequencing
Clear designation of the single diagnosis which best meets the definition of
principal diagnosis (refer 5.2.1) is critical.
All other significant diagnoses should be listed as additional.
Clinical coders cannot code “?”, “possible” or differential diagnoses as the
principal.
Clinical coders will require guidance as to whether the most significant
symptom (e.g. chest pain) or the most likely presumptive diagnosis
(e.g. angina) should be coded.
Avoid leading with symptoms if the underlying cause has been established.
For example a principal diagnosis of “cardiac syncope - atrial fibrillation new”
runs the risk of being coded primarily to a symptom code (syncope) instead
of to atrial fibrillation.
Trauma – in multiple injuries, sequence the single injury which poses the
most severe threat to life or limb, as the principal diagnosis. Where multiple
injuries are life threatening, or none of the injuries are life threatening, it is
the doctor’s prerogative to select the most severe or clinically significant
injury as principal diagnosis.
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5.2 Requirements of the discharge summary
The most important requirements of a discharge summary are that it be complete,
accurate and timely. This is necessary for adequate communication between
health care providers (e.g. between hospital doctors and the family general
practitioner). It also ensures that each inpatient episode is coded accurately and
as soon as possible after discharge. The unit and hospital activity can, thereby,
be measured, analysed, and reported on a regular basis.
A good discharge summary should include:
principal diagnosis
past history
presenting problem
additional diagnoses (complications or co-morbidities)
operations/procedures
relevant investigation results
treatment and progress
medications
future plan of management.
A complete discharge summary is required for each admitted patient episode, with
the following exceptions only:
healthy newborns (babies in their birth episode, with no peri-natal morbidity)
recurring care episodes (e.g. same day infusions, transfusions, dialysis
for treatment of the same conditions over weeks or months) – one global
discharge summary covering all episodes suffices
same day elective procedures where the operation report provides
necessary clinical details (e.g. endoscopy).
There must be supporting documentation in the discharge summary and medical
record for all diagnoses and procedures.
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5.2.1 Principal diagnosis
The principal diagnosis is defined as; The diagnosis, established after
study, to be chiefly responsible for occasioning the patient’s episode of
care in hospital (or attendance at the health care facility).
Clear designation of the single diagnosis which best meets the definition of
principal diagnosis is critical. The phrase “after study” means after evaluation of
findings to establish the condition that was chiefly responsible for occasioning the
episode of care. The condition established after study may or may not confirm the
admitting diagnosis.
Evaluation in this context considers the results of diagnostic tests performed
during the episode. It does not include information obtained from subsequent
outpatient attendances or subsequent admissions.
Procedures must not be recorded as a diagnosis. Tonsillectomy, arthroscopy,
hysterectomy, are not acceptable principal diagnoses. The reason the patient
underwent the procedure (diagnosis) should be recorded.
Events must not be recorded as the principal diagnosis e.g. “fall”, “MVA”.
5.2.2 Past history
Details regarding a patient’s relevant past medical and surgical history
(e.g. appendicectomy, CABGs, cardiac pacemaker).
5.2.3 Presenting problem
The symptom(s) which led the patient to present for treatment e.g. abdominal
pain, haematemesis, chest pain.
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Case Study 1 – Defining the Principal Diagnosis
Mrs W is an 86 year old woman, presenting for an elective booked angiogram
of her femoropopliteal circulation. She has a known background of peripheral
vascular disease, is an ex-smoker, and on presentation has dusky toes with
small healing ulcers. At preoperative review by the anaesthetist she is found
slumped in her chair, and difficult to rouse. The procedure is cancelled and she
is admitted to the medical ward for investigation of fluctuating glasgow coma
score, facial asymmetry and slurred speech. The provisional diagnoses on
admission are ‘”TIA” Arrhythmia due to cerebral hypoperfusion”.
Over the course of her five day stay, her amlodipine (for hypertension) is
ceased. Her metoprolol is halved. She has dressings to her foot ulcers and
is reviewed by the dietician for her ‘poor oral intake’. The evolving diagnosis
(progress notes 6/11/11) is ‘likely postural hypotension secondary to meds’.
Discharge Summary – Principal diagnosis: syncope secondary to meds
Mrs W’s length of stay (LOS) of 5 days was above the average LOS of 2
days for the DRG she was coded to and the cost of delivering her care was
more than the revenue the health service would receive for this patient’s care.
A review of the documentation and coding was undertaken and “buried” in
one of the paragraphs of the discharge summary was a clue to the definitive
diagnosis: “postural cerebral hypoperfusion, likely secondary to medication
causing postural drop”. The syncope (R55) was the presenting problem; it was
not the final diagnosis after study. After coding this information the admission
was reclassified to a much higher resource DRG, with a revenue increase
of $3,194.
Original
Revised
PROCEDURES
95550-00 dietician consultation
DRG
F73B syncope & collapse W/O CC
ALOS
WEIGHT
2.3
0.4999
I952 drug-induced hypotension
I951 postural hypotension
I7023 PVD with ulcer
Z530 cancelled procedure
Z8643 ex-smoker
I10
hypertension
R638 poor intake of food/fluid
95550-00 dietician consultation
F75B Other circulatory system
disorders with severe or moderate
CC
4.3
1.1220
REVENUE
$2,567
$5,761
DIAGNOSES
R55 syncope
I952 drug-induced hypotension
I7023 PVD with ulcer
Z530 cancelled procedure
Z8643 ex-smoker
I10
hypertension
R638 poor intake of food/fluid
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5.2.4 Additional diagnoses (complications and co-morbidities)
These diagnoses affect patient care in terms of requiring (for that admission) any
of the following:
commencement, alteration or adjustment of therapeutic treatment
diagnostic procedures
increased clinical care/monitoring
alteration of the standard treatment protocol for a particular procedure.
Do not include past history here unless relevant to this admission.
It is important to indicate how the condition was actively treated or assessed
for all conditions listed as “additional diagnoses”. Additional diagnoses may
be sub-categorised on discharge summaries as either complications or
co-morbidities.
Example
Type 2 diabetes Mellitus, which has required increased monitoring during
the patient’s episode of care.
Chronic Obstructive airways disease where a lung scan has been
performed.
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Co-morbid conditions
Pre-existing conditions which are clinically significant for this admission and which
may in some cases be causally linked to the principal diagnosis.
Example – co-morbidity
Chronic kidney disease (CKD) secondary to type 2 diabetes Mellitus.
Where CKD is the principal diagnosis, diabetes in this instance would
be a co-morbidity.
Complications
A complication can best be described as a condition, not present at the time of
admission, but which arises during the admission and which affects the patient’s
management and/or length of stay.
Example – complication
Infection of surgical wound
Accidental laceration of bladder during caesarean section
In its broadest sense a complication can:
be intimately related to the disease process
result from lack of an intervention (e.g. failure to treat a condition)
be related to a complex interaction between the disease process and the
intervention
be directly related to an intervention (e.g. (non) invasive procedures, surgery,
anaesthesia, medication).
Clinically relevant co-morbidities and complications can add to the cost of
providing care to that patient.
To ensure the health service is adequately funded for the level of
complexity, it is important to ensure all relevant co-morbidities and
complications are documented and coded correctly.
If a condition or injury is related to a surgical/procedural intervention, rather
than being related to the patient’s disease process, then this should be
clearly documented in the progress notes and/or operation report and on the
discharge summary e.g. ‘acute urinary retention following hernia repair, requiring
catheterisation. Patient also has benign prostatic hypertrophy (BPH)’.
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Based on this documentation the coder cannot correctly assign the urinary
retention code as it is not clear whether the urinary retention is directly related
to the surgery or is associated with BPH. Similarly, use of the term “post-op
urinary retention” only advises that the retention occurred in the post operative
period. Use of the terms “due to” or “secondary to” clearly define a clear causal
relationship between the procedure and the urinary retention enabling the coder to
capture the procedural complication.
5.2.5Operations/procedures
The principal procedure is the most significant procedure that was performed for
treatment of the principal diagnosis. All significant procedures undertaken from the
time of admission to the time of discharge should be documented. This includes
diagnostic, therapeutic and allied health procedures.
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Case Study 2 – Specifying the Diagnoses
Mr J is an 82 year old admitted to a metropolitan non-teaching hospital with
increasing right shoulder pain and lower back pain with some lower limb
weakness. He has a history of ‘bowel cancer’, resected in 2003 but has been
well since. He is an ex-smoker. Correspondence elsewhere in the notes
confirms a recto-sigmoid primary in 2003.
He has an x-ray of the right shoulder which shows a large metastatic deposit
in the humeral head. His bilateral lower limb weakness worsens and is later
referred to in the progress notes as ‘paraplegia’.
A CT scan shows a pathological fracture in the T7 vertebral body with
metastases also in T8 and L2.
Oncologist review 15/2/11: now has spinal cord compression with metastases
in spine and humerus. He is transferred to a teaching hospital for radiotherapy
and further management on 15/2/11. He returns to this site at a later date for a
palliative care episode which ends with his death on 16/3/11. LOS 6 days.
Discharge Summary: Principal diagnosis – metastatic bowel cancer
This diagnosis was not specific regarding the condition responsible for the
admission. A review of the medical record identified the following: “ Admitted
with shoulder pain and LL weakness. X-ray showed large humeral head mets.
CT: path # T7 and mets T8/L2”. The admission was reclassified to a higher
resource DRG, with a revenue difference of $16,120.
Original
DIAGNOSES
PROCEDURES
Revised
C260 neoplasm, malignant, intestine, not further
specified
G992 neoplastic myelopathy
G952 cord compression
G819 hemiplegia
C795 metastases bone
Z8643 ex-smoker
nil
DRG V6.0
G60B Digestive malignancy
W/O Ccc
ALOS
WEIGHT
REVENUE
4.7
.8918
$4,579
C795 metastases-bone
M9078 bone fracture in neoplastic disease
G8221 paraplegia, acute
G992 neoplastic myelopathy
G952 cord compression
C19 recto-sigmoid primary
Z8643 ex-smoker
nil
B60B Acute paraplegia/
quadriplegia +/- Operating Room
Procedures W/0 Ccc
10.7
4.0311
$20,700
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Case Study 3 – Documenting Procedures
50 year old Mr Y is a type 2 diabetic on insulin, with a past history of
hypertension, dyslipidaemia, chronic kidney disease stage 4, and peripheral
neuropathy. He is a smoker. He is admitted via ED with necrotic toes, for IV
antibiotics and control of blood sugars. LOS 5 days.
Discharge Summary: Principal diagnosis – Necrotic Diabetic Toes
Procedures – IV antibiotics, control of BSL
Review of documentation identified an entry in the progress notes of 22/10/10:
“BSLs still uncontrolled, on the ward: debrided hallux, no anaesthetic due to PN,
ulcer down to bone, and subcutaneous necrotic medial ulcer.”
The most significant procedure (debridement) was omitted from the discharge
summary, and the clinical coder misses it completely in the progress notes. A
complete discharge summary would have provided a ‘safety net’ for the coder.
After coding this information the admission was reclassified to a higher resource
DRG, with a revenue increase of $15,809.
Original
Revised
E11.73 diabetic foot ulcer
R02 necrosis skin/subcut
E11.42 Diabetes with peripheral neuropathy
E11.22 Diabetes with established nephropathy
E11.71 DM2 with multimicrovasc comps
N18.4 CKD stage 4
I0 hypertension
E11.65 poorly controlled DM2
Z72.0 smoker
Z92.22 long-term use of insulin
90665-00 debridement skin and
subcutaneous tissue
K01B Operating Room Procedures
for Diabetic complications W/O Ccc
DIAGNOSES
E11.73 diabetic foot ulcer
R02
necrosis skin/subcut
E11.42 Diabetes with peripheral neuropathy
E11.22 Diabetes with established nephropathy
E11.71 DM2 with multimicrovasc comps
N18.4 CKD stage 4
I0 hypertension
E11.65 poorly controlled DM2
Z72.0 smoker
Z92.22 long-term use of insulin
PROCEDURES
nil
DRG V6.0
K60B Diabetes W/O Cscc
ALOS
WEIGHT
4
.9712
13
4.0499
REVENUE
$4,987
$20,796
Although the DRG (K01B) states operating room procedures, any procedure so
classified may still be performed on the ward. Operating room in this sense is
an indicator of level of service, rather than location.
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5.2.6 Relevant investigation results
Include the results of all investigations conducted, which are considered to have a
bearing, or impact on the management of the patient during the episode of care.
5.2.7 Treatment and progress
Describe in significant detail, the patient’s treatment and progress during this
episode of care.
5.2.8Medications
Current medications indicating the status of each medication relative to the
admission status (new, increased dose, decreased dose, ceased or unchanged)
with dose, duration, purpose and supply.
Provide information regarding current medications indicating the status of each
medication relative to the admission. Include:
generic name (or brand name where relevant e.g. combination products)
dose
drug status (changes to therapy between pre-admission and discharge e.g.
increased or decreased dose)
rationale for changes
surveillance requirements for interactions
expected outcomes
any adverse drug reactions experienced in hospital
patient counselling on administration.
5.2.9 Future plan of management
Describe details regarding the plans for managing the wellbeing of the patient in
the future. Relevant information given to the patient e.g. activity level, wound care.
Follow up arrangements including referrals to other health care providers.
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6. Sample discharge summary
Medical Records Copy
WA Health Hospital
Patient:
FINE, ADAM BRUCE
189 ROYAL STREET
EAST PERTH 6004
dob: 7 June 1934
Admitted: 15 May 2010
Discharged:
03 June 2010
LOS:20 days
D/C Reason:
Care Complete (Clinician’s Decision)
D/C Destination: Private Residence – Self Caring
Specialty:
Department of General Medicine
Consultant:
HIGGINS, HENRY
Principal Diagnoses: (responsible for admission)
– Glaucoma
Secondary Diagnoses/Complications:
(which were treated or delayed discharge/progress)
– Acute renal Insufficiency
– Urethral Bleeding – Male
– Urinary Retention
– UTI
Other Conditions/Problems:
(active conditions/problems during this admission)
– Diabetes Mellitus
– Hypertension
Interventions/Procedures: (during this admission)
– Trabeculectomy
– Cystoscopy
History:
Emergency admission for trabeculectomy and 5FU injection for primary open
angle glaucoma with high IOP not responding to maximum medical therapy
(via Eye Clinic Outpatient appointment)
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Findings:
IOP 38mm Hg
Interpreted Summary of Significant Results:
On admission:
– UEC: Na 139 K 4.1 BC 25 Ur 8.5 Cr 98
Post-op:
– Bladder scan >1000ml
– UEC
Na 140 K 4.1 BC 22 Ur 11.0 Cr 123
– Urine
E Coli on 24/05/10, fully sensitive to antibiotics
– CT head 27/05/10 – No acute changes / bleed / infarct
On discharge:
– Bloods done in Rehab Ward at the time of discharge,
– FBP
Hb120 WCC 8.8 Platelet 321 7.03
– Ue
Na 144 K 4.0 BC 29 Ur 8.9 Cr 103
– CRP92
– MG 0.77
(0.7 – 1.10)
– PO4
0.93
(0.80 – 1.50)
– VIT B12 AND FOLATE NORMAL
– VIT D 26
(>50 nmol/L)
– TFT
TSH 0.95 T4 18
Clinical Management:
1.Admitted for surgery as described above, which proceeded without
complication on Thursday evening
2.Postoperatively the nursing staff noted he had a distended bladder on
bladder scan, and an IDC was inserted as per protocol, draining 1750ml in
20 minutes
3.Overnight (15/5/10) the patient became confused and removed his IDC,
resulting in urethral trauma and frank haematuria. Attempts to reinsert IDC
failed on the ward
4.The following morning (16/5/10), Urology were consulted and an IDC
inserted via flexible cytoscopy
5.Nil further problems noted postoperatively, with nil further episodes of
confusion and clear urine draining via IDC
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Transferred to GRU for further rehab.
1.Medically – Episodes of visual and auditory hallucinations while in the ward.
Patient aware that he is hallucinating. Stated that he had similar episodes
before. No records re: the above found from the old notes or from the GP.
Investigated. No cause suggestive of hallucinations noted except for E coli
UTI which was treated with Trimethoprim. Hallucinations subsided few days
later.
2.Mobility – Remained independent in mobility and all ADL.
3.Cognition-Query re decreased cognition and STML during admission in the
ward. OT and SW assessment showed no significant STML. CT scan head
showed no significant change. No need for further assessment at this point
in time.
Social Issues:
Lives alone. Normally independent with all ADL. NO SERVICES IN PLACE.
Silverchain referral done for regular eye care.
Things to Note:
1.Glaucoma – please encourage Mr Fine to remain compliant with glaucoma
medications his right eye should be normotensive as a result of surgery but
his left eye is still at risk.
2.Eye clinic follow-up 11/06/10.
3.UTI, repeat MSU if clinically relevant.
4.Mr Fine might benefit from an OP psychogeriatric review if there are further
episodes of hallucinations.
Information to Patient:
You will need to attend the OP eye clinic on 11/06/10
Review Details:
Eye Clinic follow-up 11/06/10
Copies To:
Patient, Consultant, Medical Records
Dr John Dolittle, WA Health Medical Centre
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Discharge Medications:
Medication
Dosage
Atorvastatin Calcium Tablets 40mg
1 at bed time
Irbesartan Tablets 300mg
1 in the morning
Chlorsig Eye Ointment 1%
1 in the morning
1 in the evening
Gliclazide Mr Sr Tablet 30mg
1 in the morning
Metformin hydrochloride Tablets 850mg
1 in the morning
1 in the evening
Nifedipine Sr Tablets 30mg
1 in the morning
Ocuflox Eye drops 3mg **New**right eye
1 in the morning
1 at midday
1 early evening
1 at bedtime
PredForte Eye drops **New** right eye
1 in the morning
1at midday
1 at midday
1 early evening
1 at bedtime
Tamsulosin hydrochloride Caps 400mcg
1 in the morning
Travatan Eye drops 40mcg **New**
LEFT eye
1 at bedtime
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Reason(s) Special
Instructions
Clinical case studies
Clinical case
studies
Version 3.0
Case Study 4 – Mobilising after a Model of Care
Patient:
Principal Diagnosis:
Date of Admission:
Date of Discharge:
Length of Stay:
Mr William White
Fractured Neck of Femur
09/07/2012
12/07/2012
3 days
Best evidence-based practice improves quality of care
for the patient
Mr White, a 71 year old male living independently at home, arrives by ambulance
at the Emergency Department (ED) early one morning after falling and injuring his
left hip.
A hip and pelvic x-ray confirms a fractured
neck of femur. The ED staff commence
Mr White on the Hip Fracture Clinical
Pathway with a regional femoral nerve
catheter inserted for pain management.
Mr White is then transferred to the
orthopaedic ward as a priority. He is
reviewed by the orthogeriatric team for
medical stabilisation before surgery later
that morning.
On day one after his surgery Mr White
begins his multidisciplinary rehabilitation
which includes daily orthogeriatric,
physiotherapy and occupational therapy
review. His intravenous fluids are ceased
and an oral diet is introduced. His
indwelling catheter is removed. Mr White
sits out of bed, is mobilised and up to
shower.
The orthogeriatric team review Mr White
and find he is medically stable and
recovering well. They address his risk
of osteoporosis and falls. On day three
post-op Mr White is waitlisted for and
transferred to a nearby rehabilitation unit.
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What the doctor said
“By developing, implementing and following the Hip Fracture Clinical Pathway
we have greatly improved patient care, reduced complications and decreased
length of stay for hip fracture patients.”
What does this mean under Activity Based Funding?
Mr White’s diagnosis related group (DRG) was Other Hip and Femur
Procedure without catastrophic or severe complications and/or
co-morbidities (I08B).
The DRG revenue for I08B, which is based on the average cost for the
average length of stay, is $16,9911.
The average length of stay for I08B is 8.33 days. Mr White’s length of stay
was shorter.
The health service is likely to be fully reimbursed for the cost of his care.
The health service will receive a Fragility Hip Fracture Treatment premium
payment of $200.
What we learnt from Mr White
Benefits of Best Practice
By following the Hip Fracture Clinical Pathway Mr White’s clinical team were
able to provide timely delivery of best practice care. He received an early
comprehensive assessment, multidisciplinary care, rapid definitive treatment and
early mobilisation.
Delivering Quality
The Orthogeriatric Model of Care ensures quality care for older patients and the
most efficient length of stay. It can reduce the likelihood of complications such
as delirium, urinary tract infections and constipation. These complications are
uncomfortable for the patient and can increase their length of stay.
Cost Effective Care
The Hip Facture Pathway allowed Mr White to commence rehabilitation within
days and return home within a week. A short length of stay is preferable for the
patient and is also cost effective. The efficiency of the hospital is increased by
reducing bed block and allowing more patients to be treated.
Premium Payment
Under Activity Based Funding and Management a Premium Payment Program
has been designed to recognise and reward services which provide a high level
of best evidence-based care. Mr. White’s care satisfied the six clinical indicators
required to receive a Fragility Hip Fracture Treatment premium payment of $200.
Calculated using Independent Hospital Pricing Authority(11) acute admitted patients AR-DRG v 6.x price
weights and Health Activity Purchasing Intentions 2012-2013(4) state efficient price of $5135
1
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Case Study 5 – Resourcing Roadblocks
Patient:
Date of Admission:
Date of Discharge:
Length of Stay:
Mrs Patricia Purple
Chronic obstructive pulmonary disease
with acute lower respiratory infection
07/01/2012
02/03/2012
55 days
Management of long stay patients is important
Mrs Purple is an 80 year old woman with severe Chronic Obstructive Pulmonary
Disease (COPD) on home oxygen with a full time carer. She arrives at hospital by
ambulance with a reduced conscious state after experiencing significant difficulty
breathing.
On admission she is found to have an acute exacerbation of COPD and is
treated with non-invasive ventilation (NIV). An initial wean off is unsuccessful
with worsening respiratory failure and signs of right heart failure. A slower wean
is initiated. While successful during the day she continues to require the NIV unit
at night. On day 28 Doctors conclude Mrs Purple is medically well enough to
continue her treatment from home under the proviso a NIV unit can be sourced
and her carer is trained in its use. She is motivated by the opportunity to continue
her treatment from home.
Efforts to source the NIV unit are met
with a number of roadblocks. Staff
experience difficulty identifying the
appropriate process to follow and the
right people to engage causing Mrs
Purple’s discharge date to be pushed
back. She develops a urinary tract
infection and is treated with antibiotics.
After some negotiation, management
agree to fund a monthly rental of the
NIV unit. Community based assistance
is sourced so that Mrs Purple’s
carer can be trained. Mrs Purple is
discharged on day 55.
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What the Doctor said
“If clinicians had the right tools available to them, including equipment and
community based respiratory nurses, the management of this patient’s
hospital stay could have been very different and significantly shortened.”
Mrs Purple’s diagnosis related group (DRG) was Respiratory System
Diagnosis with Non-Invasive Ventilation (E41Z)
The DRG revenue for E41Z, which is based on the average cost for the
The average length of stay for E41Z is 11 days. Mrs Purple exceeded this
by 44 days.
The health service is unlikely to be fully reimbursed for the cost of her care.
What we learnt from Mrs Purple
Proactive Discharge Planning
Mrs Purple’s length of stay could have been reduced had a clear care pathway
been in place earlier on. This would involve defining the resources required, the
expertise to involve and at what time.
Resource Management
Resources such as the NIV unit have the potential to move long stay patients out
of an acute inpatient setting and into home-based care. This is preferable for the
patient and is also cost effective.
Episode of Care Change
A length of stay post 35 days is considered non-acute care. At this point Mrs
Purple’s could have received a change in care type to a maintenance care DRG.
This would have reduced the acute care DRG length of stay and increased
funding.
Cost Savings
A NIV unit would cost the Health Service around $2500. The cost of providing
acute inpatient care in the absence of an NIV unit is far greater. Having this unit
available for COPD patients like Mrs Purple to use from home would represents
a cost saving for the Health Service. It would also reduce the incidence of future
readmission and potential future costs.
Patient Safety
Mrs Purple developed a preventable urinary tract infection causing discomfort and
further treatment. Resource management can shorten a patient’s length of stay
reducing their exposure to infection and risk of adverse events.
1
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Case Study 6 – The Untimely Transfer of Information
Patient:
Date of Admission:
Date of Discharge:
Length of Stay:
Mr Robert Red
Perforation of Oesophagus
10/10/2011
30/10/2011
20 days
Good clinical handover is essential for protecting
patient safety
Mr Red, a 69 year old man with a history of diabetes, smoking, high cholesterol
and hypertension, presents at a peripheral hospital one evening with sudden
onset of central chest pain associated with vomiting. Following an examination
and available basic investigations, the team formulate a differential diagnosis,
including acute coronary syndrome and possible oesophageal rupture, both
of which require transfer to a tertiary hospital for further investigation and
management.
A phone conversation is made to a cardiothoracic surgeon who recommends
a CT contrast swallow but this is not documented on the transfer form. When
Mr Red arrives at the tertiary hospital Emergency Department the transfer
documentation simply states his presenting complaint as ‘high risk chest pain
for investigation.’
Mr Red is admitted under the cardiology team and undergoes serial ECGs and
blood test for acute coronary syndrome. The following afternoon the possibility
of oesophageal rupture due to vomiting is realised. A CT contrast is performed
and reveals a lower oesophageal rupture. Mr Red is taken immediately to surgery
for repair.
Mr Red makes a full recovery however
the delay in diagnoses and treatment
contributed to development of an
infection which increased his length of
stay by 14 days.
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“The term “high risk chest pain” generally refers to pain which is thought likely
to be due to a cardiac cause such as myocardial infarction or angina. In Mr
Red’s case he has a number of pre-existing risk factors for heart disease
therefore no question was raised regarding the potential cause for chest
pain after he arrived at the tertiary hospital. We understood he had been
transferred for cardiology workup. Had we known about the involvement of
cardiothoracic surgery and the possibility of oesophageal perforation we
could have arranged the CT scan to be done on arrival and would have made
the diagnosis much earlier.”
Mr Red’s complicating sepsis resulted in a diagnosis related group (DRG) shift
from Stomach, Oesophageal and Duodenal Procedure with severe or moderate
complications and/or co morbidities (G03B) to with catastrophic complications
and/or co morbidities (GO3A).
What does this mean for the Health Service providing Mr Red’s care?
A longer average length of stay.
A greater consumption of resources.
A higher average cost.
What we learnt from Mr Red
Good Clinical Handover
Mr Red’s story highlights the importance of good clinical handover in protecting
patient safety. Mr Red suffered an infection causing additional concern for his
family and friends. It increased his length of stay and subsequent cost to the
health service.
Improving Clinical Documentation
Accurate and timely clinical documentation is fundamental in the transfer of
patient care from one hospital to another. Had the CT contrast swallow request
been clearly documented in Mr Red’s handover he may have been diagnosed
hours earlier, reducing his risk of infection and improving his outcome.
Managing Resources
Mr Red underwent a number of ECGs and blood tests which had already been
performed at the original hospital. Repeat tests use valuable resources and time
which could have otherwise been used on other patients.
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Case Study 7 – A Delay in Discharge
Patient:
Date of Admission:
Date of Discharge:
Length of Stay:
Mr Gavin Grey
Left ventricular failure and pneumonia
17/04/2012
25/04/2012
8 days
Early engagement of a social worker when required
will facilitate a timely discharge for the patient
Mr Grey, an 84 year old man with heart disease and throat cancer, presents at the
emergency department with shortness of breath, fever, and a productive cough.
During his initial assessment the Doctor notices that Mr Grey appears quite
unkempt and he is not keen to talk about his social situation. The Doctor writes
a comprehensive problems list in the patient notes including ‘heart failure’ and
‘chest infection’ but does not note Mr Grey’s appearance or his attempt to gather
collateral information about his social circumstances.
During Mr Grey’s hospitalisation his condition gradually improves. On day five Mr
Grey is medically much better but at the discharge planning meeting his family
express concerns about his ability to cope at home.
A social worker becomes involved and contacts Mr Grey’s daughter who reveals
significant concerns that Mr Grey is not eating much, not showering and not
taking all of his medications. She also suspects he is depressed since the death
of his wife and has noticed some short term memory problems over the past three
months. These issues require a family meeting and negotiation with Mr Grey to
accept support services at home as well as a review by the psychogeriatric team.
Mr Grey is discharged on day eight.
What the Social Worker said
“When concerns about a patient’s
ability to cope at home are identified
during the patient’s initial presentation,
an early referral to Social Work allows
the time to ascertain the full social
picture, assess risk, engage family
and refer to the appropriate services.
In this case the patient could have
been discharged on day five when he
was medically ready.”
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“It is essential we build a comprehensive problem list, put them in the notes
and make sure we follow through all issues related to patients when they are
admitted, rather than just focus on the presentation and a single diagnosis.
This is about holistic care of patients and through that timely and patient
(rather than disease) focussed care.”
Mr Grey’s diagnosis related group (DRG) was Heart Failure and Shock
without catastrophic complications and/or co morbidities (F62B).
The DRG revenue for F62B, which is based on the average cost for the
The average length of stay for F62B is 5 days. Mr Grey exceeded this
by 3 days.
The health service is unlikely to be fully reimbursed for the cost of his care.
What we learnt from Mr Grey
Multidisciplinary Engagement
In Mr Grey’s case engagement of a social worker ensured he was referred to the
appropriate community based support services. His home situation was improved
having a positive impact on his health, reducing stress on his family, reducing the
likelihood of readmission and associated costs.
Documentation in Progress notes
Mr Grey’s problem list over time focused on his medical illness but did not include
his social issues. A daily comprehensive problem list should consider the whole
patient situation. All medical and emotional issues should be addressed before
discharge can occur.
Improved Communication
Mr Grey’s potential social issues could have been communicated to a social
worker at the start of his admission. He would have received a more timely
assessment, reducing his length of stay and subsequent cost to the health
service.
Reduce Costs by Improving Quality
Safe high quality care costs less in the long term. It can reduce the incidence
of readmission which is better for the patient and their family and represents a
potential cost saving for the health service.
1
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Case Study 8 – How Harmful is your Handover?
Patient:
Date of Admission:
Date of Discharge:
Length of Stay:
Mr Gilbert Green
Chronic obstructive airways disease
15/01/2012
16/03/2012
61 days
Safe Handover Safe Patients
Mr Green, an 88 year old man with severe Chronic Obstructive Pulmonary
Disease (COPD), is brought to the emergency department one weekend with
breathlessness and chest pain on breathing in. ‘Exacerbation of COPD’ and
‘Unlikely PE’ are documented in his admitting notes and Mr Green is transferred
to the ward.
While his risk of pulmonary embolism (PE) was assessed to be low a D-dimer
blood test is ordered and returns with an elevated value. While inconclusive,
a phone call is made to the on-call junior doctor to write up a dose of blood
thinners until further investigations could be arranged in the morning. The dose
is prescribed on the anticoagulant medication chart and administered. It is not
written in the case notes or noted on the regular medication chart.
At handover the next morning, following a
busy night on the ward, his blood thinner
medication is not discussed. Mr Green was
feeling better so his specialist felt PE was
unlikely and the chest pain had been due to
coughing and an infective exacerbation of
COPD.
A few days later Mr Green falls while taking
himself to the bathroom and hits his head. He
is later found confused. A CT scan reveals
a large subdural haematoma (a collection
of blood within the skull). He is taken to
theatre by a neurosurgeon and the blood is
drained. He slowly improves after intensive
rehabilitation for his head injury. Mr Green is
discharged on day 61.
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“We know how easy it is to do just a brief handover when we are busy which
can have potentially tragic outcomes. That is why as a consultant I insist
we sit down and focus on the handover and use the iSoBAR framework to
ensure all important issues are discussed.”
Mr Green suffered a complication unrelated to his COPD which required
surgery therefore his diagnosis related group (DRG) was Operating Room
Procedure unrelated to Principal Diagnosis with catastrophic complications
and/or co morbidities (801A).
The DRG revenue for 801A, which is based on the average cost for the
average length of stay is $37,1301.
The average length of stay for 801A is 21 days. Mr Green exceeded this by
40 days.
The health service is unlikely to be fully reimbursed for the cost of his care.
What we learnt from Mr Green
Document Medication
Accurate documentation and daily review of medication charts can improve
patient safety and reduce costs. Mr Green’s blood thinner medication increased
his risk of intracranial bleeding following his fall. The medication should have been
written in his case notes and communicated during handover.
Use iSoBAR Handover
Mr Green may have benefited had his clinicians used the iSoBAR framework
during handover (identify, situation, observation, background, agree on a plan,
readback). This is a structured method of handover that supports safe patient
care.
Clinical Risk Management
If all staff had been aware that Mr Green was on blood thinner medication they
may have increased fall prevention strategies or post fall interventions.
Improve Patient Journey
Mr Green suffered a large subdural haematoma which increased his length of stay
by many weeks. During his prolonged hospitalisation he underwent many tests,
procedures and intensive rehabilitation. The impacted his quality of life and that of
his family and friends.
1
48
Common complications
and co-morbidities
Common
complications and
co-morbidities
Version 3.0
Common complications and co-morbidities
Acidosis or alkalosis, metabolic or respiratory
Bronchiectasis
Acute myocardial infarction, NSTEMI or STEMI
Agranulocytosis
Anaemia, please specify type e.g. Due to blood loss, acute or chronic,
aplastic, etc.
Angina pectoris, unstable or stable
Atrial fibrillation or flutter
Candidal infections, specify site
Cardiogenic shock
Cardiomyopathy, specify type
Cellulitis
Cerebral infarction
Cirrhosis of liver (Alcoholic or Non-Alcoholic)
Chronic Obstructive Pulmonary Disease
Chronic viral hepatitis C, B etc
Coagulation defects
Complications following infusion, transfusion and therapeutic injection
e.g. Transfusion reactions
Congestive heart failure
Decubitus (pressure) ulcer, specify stage
Delirium, acute brain syndrome and underlying cause if known
Diabetes mellitus (specify any micro or macro vascular complications)
and type
Dementia, specify type
Disruption or dehiscence of wound
Embolism and/or thrombosis
Haemorrhage and haematoma complicating a procedure
Heart valve stenosis/regurgitation
Hereditary factor deficiency
Hypokalaemia/hyperkalaemia
Hypopituitarism
Hyperosmolality and hypernatraemia/hyponatraemia
Ileus
Infection and inflammatory reactions due to internal devices
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Intestinal obstruction (and cause if known)
Impaction of intestine
Interstitial pulmonary diseases
Left ventricular failure
Mechanical complications of any devices or implants including:
Breakdown (mechanical)
Displacement
Leakage
Malposition
Obstruction
Mechanical Perforation
Protrusion
Mechanical complication of internal joint prosthesis
Pathological fractures
Phlebitis and thrombophlebitis of any vessel
Pleural effusion
Pneumonia, specify organism is known
Pneumonitis, aspiration
Post procedural respiratory disorders
Pulmonary collapse/atelectasis
Pulmonary embolism
Pulmonary hypertension, primary or secondary
Renal failure, acute or chronic
Renal impairment, acute or chronic
Respiratory failure, acute or chronic. Note: Please specify chronicity as
respiratory failure “unspecified” does not affect DRG assignment
Retention of urine
Sepsis, identify organism
Tachycardia or other arrhythmias
Thalassaemia, specify type and variant
Thrombocytopenia, primary or secondary
Ulcers of any site
Use of Alcohol/Drugs, specify dependence, harmful use, withdrawal,
withdrawal with delirium
Ventricular fibrillation and flutter
Wound infection following a procedure.
50
Appendixes
Appendixes
Version 3.0
Appendix A
AR-DRG major diagnostic categories
AR-DRG
range
PreMDC
A
Transplant
MDC
A01Z-A40Z
MDC Description
B
Nervous System
B01Z-B82C
C
Eye
C01Z-C63Z
D
Ear, Nose Mouth and Throat
D01Z-D67B
E
Respiratory System
E01A-E76Z
F
Circulatory System
F01A-F76B
G
Digestive System
G01A-G70B
H
Hepatobilliary System and Pancreas
H01A-H64B
I
Musculoskeletal System and Connective Tissue
I01A-I79B
J
Skin, Subcutaneous Tissue and Breast
J01A-J69C
K
Endocrine, Nutritional and Metabolic Diseases and
Disorders
K01A-K64B
L
Kidney and Urinary Tract
L02A-L68Z
M
Male reproductive System
M01A-M64Z
N
Female reproductive System
N01Z-N62Z
O
Pregnancy, Childbirth and the Puerperium
O01A-O66Z
P
Newborns and other Neonates
P01Z-P67D
Q
Blood and Blood Forming Organs and Immunological
Disorders
Q01Z-Q62Z
R
Neoplastic
R01A-R64Z
Infectious and Parasitic
S60Z-T64C
U
Mental Health
U40Z-U68Z
V
Alcohol/drug
V60Z-V64Z
Injuries, Poisonings and Toxic Effects of Drugs
W01Z-X64B
Y
Burns
Y01Z-Y62B
Z
Factors Influencing Health Status and Other
Contacts with Health Services
Z01A-Z65Z
S, T
W, X
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Appendix B
The AR-DRG classification system
B.1Structure
The AR-DRG classification system has a logic that reveals:
1.The broad group (usually the MDC) to which the DRG belongs
2.The adjacent DRG (and the adjacent DRG’s location in terms of a tripartite
distribution between medical surgical and other partitions)
3.The existence/nature of splits based on resource consumption.
The format of each AR-DRG number consists of four alphanumeric characters
organised in terms of ‘ADDS’. These are described in the following sections(7).
A D D S
B.2Broad group
A
indicates the broad group to which the DRG belongs:
Different letters of the alphabet have been used to signify the broad group
while the number 8 has been used to identify a residual group of DRGs
which capture atypical cases (Operating Room Procedures Unrelated to
Principal Diagnosis)
See Appendix A for all 23 MDCs.
B.3Adjacent DRG
DD
identifies the partition to which the DRG belongs.
01 – 39
indicates surgical partitions
40 – 59
indicates other partitions
60 – 99
indicates medical partitions
The second and third characters are digits. DRGs that begin with the same
letter and share the same middle digits are called adjacent DRGs e.g. A01B
and A01C.
Within the surgical and other partitions, the adjacent DRGs are generally
ranked from highest to lowest resource consumption e.g. B01 has higher
resource consumption than B06.
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B.4Split indicator
S
is a split indicator that ranks DRGs within adjacent DRGs on the basis
of their consumption of resources. The last character designates the
relative importance of DRGs within an adjacent DRG in terms of resource
consumption; any one of a number of values may be used:
A
highest consumption of resources within adjacent DRG
B
second highest consumption of resources
C
third highest consumption of resources
D
fourth highest consumption of resources
Z
no split for the adjacent DRG
The meaning of the split indicator may be gathered from the names of the DRGs.
For example:
B70A Stroke and Other Cardiovascular Disorders W Catastrophic CC
B70B Stroke and Other Cardiovascular Disorders W Severe CC
B70C Stroke and Other Cardiovascular Disorders W/O Catastrophic or Severe CC
B70D Stroke and Other Cardiovascular Disorders, Died or Transferred
<5 Days
E63Z Sleep Apnoea (the only DRG in adjacent DRG E63)
B.5AR-DRG treatment of severity
Complication and Co-morbidity Levels (CCLs)
Complication and Co-morbidity Levels (CCLs) are severity weights which are
given to all diagnoses. The values are:
0 = the code is not complication or co-morbidity; or
the code forms part of the definition for the adjacent DRG; or
the code is excluded as a complication/co-morbidity in the assigned adjacent DRG; or
the code is a complication/co-morbidity, but is closely related to the principal diagnosis; or
exactly the same code appears elsewhere in the record
1 = the code is a minor complication/co-morbidity
2 = the code is a moderate complication/co-morbidity
3 = the code is a severe complication/co-morbidity
4 = the code is a catastrophic complication/co-morbidity
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Patient Clinical Complexity Levels (PCCLs)
From these CCLs a Patient Clinical Complexity Level (PCCL) is calculated
for each episode using a complex algorithm. The PCCL calculation has been
designed to prevent similar conditions from being counted more than once. A
PCCL value of:
0 = no CC effect
1 = minor CC
2 = moderate CC
3 = severe CC
4 = atastrophic CC
B.6Example 1: DRG assignment
I03B Hip replacement W/O catastrophic CC
Principal Diagnosis: Other primary throsis
M161
Procedure:
Total arthroplasty of hip, unilateral
4931800
Other Procedure:
General anaesthesia
9251429
PCCL
0 – SDX is not a CC, or is included
in ADRG definition, or is excluded
AR-DRG:
I03B Hip replacement W/O
Catastrophic CC
Principal Diagnosis: Other primary coxarthrosis
M161
From the principal diagnosis, a MDC can be determined i.e. Other primary
coxarthrosis is classified under Musculoskeletal system and connective tissue (I).
I D D S
Procedure:
4931800
Other Procedure:
General anaesthesia
9251429
Procedure and other procedure classify this episode under a surgical partition. A
classification of 03 is assigned to demonstrate higher resource consumption.
I 0 3 S
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PCCL
0 – SDX is not a CC, or is included in ADRG definition, or is excluded
Finally, a Patient Clinical Complexity level of 0 indicates there is no complication
or co-Morbidity effect. The episode is thus given a split indicator rank B
demonstrating second highest consumption of resources.
Note: The split indicator rank in this case is attributed to the procedure requiring a
high level of resources due to prosthetics etc rather than a high level of resources
due to the risk of a high CCL.
I 0 3 B
B.7Example 2: DRG assignment
I03A Hip replacement W Catastrophic CC
Principal Diagnosis: Other primary coxarthrosis
M161
Other Diagnosis:
Systemic inflammatory response
syndrome (SIRS) of infectious origin
with acute organ failure CC, CCL = 3
R651
Procedure:
4931800
Other Procedure:
General anaesthesia
9251429
PCCL
4 – SDX is a catastrophic CC
AR-DRG:
I03A Hip replacement W
Catastrophic CC
Other Diagnosis:
N179
Systemic inflammatory response syndrome (SIRS) of infectious origin
with acute kidney failure CC, CCL = 3
Principal diagnosis remains as in Example 3.6. Other diagnosis introduces a
complication and co-morbidity level of 3 where the code is a severe CC.
Procedure and Other Procedure remain as in Example 3.6.
I 0 3 S
55
R651
Version 3.0
PCCL
4 – SDX is a catastrophic CC
Due to the added CCL level, the Patient Clinical Complexity Level is now elevated
to 4 demonstrating a catastrophic CC. Therefore the DRG assignment will now be:
I 0 3 A
B.8Impact of CCs on cost signature
In theory, a DRG with complications and co-morbidities would have higher
average nights of stay,), when compared to a DRG without complications and comorbidities.
DRG W
Catastrophic CC
DRG W/O
Catastrophic CC
Central Episode
COST
Central Episode
NIGHTS OF STAY
Diagram 4: Illustrates the cost signature of two adjacent DRGs, one with
Catastrophic CC and one without Catastrophic CC.
Note: This would be the expected effect in general terms. On a case-by-case
basis, these elements may be subject to change and may not hold.
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Appendix C
Glossary
ACCC
Australian Clinical Casemix Committee
ACHI
Australian Classification of Health Interventions
ACS
Australian Coding Standards.
AR-DRGs
Australian Refined Diagnosis Related Groups. This
DRG system has been developed to appropriately
reflect clinical practice in the Australian health care
environment.
Casemix
The types or mix of patients that a particular hospital
treats.
CCL
Complication and co-morbidity levels: severity weights
given to all associated diagnoses in order to calculate
the PCCL (see below).
CCs: Complication
or Co-morbidities
Those conditions that because of their presence with a
specific principal diagnosis, would cause an increase
in length of stay by at least one day. In the DRG
description Preceded by W or + (with) or W/O or
- (without).
Co-morbidities
The condition(s) that exists at the time of the admission
which affect patient care in terms of requiring treatment,
diagnostic procedures and increasing nurse care/
monitoring.
Complications
The condition(s) not present on admission, which arises
during the patient’s stay which affects the treatment of
the patient.
Ccc
Abbreviation in the DRG description for Catastrophic
comorbities or complications. Preceded by W or + (with)
or W/O or - (without).
Scc
Abbreviation in the DRG description for Severe comorbidities or complications. Preceded by W or + (with)
or W/O or - (without)
Cost Weight
The weight assigned to a DRG which reflects the
amount of hospital resources an average patient in that
DRG is expected to consume for that admission relative
to other DRGs.
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DRG (Diagnosis
Related Group)
A patient classification system used to relate the number
of type of patients treated in a hospital (the casemix)
to the resources required by the hospital to treat those
patients.
DRG Grouper
A software package that assigns each patient discharge
one particular DRG, according to their discharge
diagnosis(es) and, if applicable, procedure(s) the patient
underwent during their stay, age and discharge status.
ICD-10-AM
International Statistical Classification of Diseases and
Related Health Problems, 10th Revision, Australian
Modification. The coding classification system used to
classify the diagnoses and procedures of every inpatient
separation.
LOS
Length of stay.
MBS
Medicare Benefits Schedule
MDC (Major
Diagnostic
Category)
23 categories that relate to main body systems. After
discharge, patient admissions are classified into an
MDC (according to the ICD-10-AM code) before they
are further defined and classified into a DRG.
NCCC
National Casemix and Classification Centre (NCCH
defunct as of 1 July 2010)
NOS
Nights of stay.
Outlier
An outlier is a case, which either clinically or statistically
does not fit with most of the other cases assigned to
the DRG. Length of stay and/or cost are the major
measures used for identification of outliers.
PCCL
Patient clinical complexity level: calculated on CCL
combinations using an algorithm. Each DRG will have a
PCCL calculated.
Principal Diagnosis
The condition established after study to be chiefly
responsible for occasioning the admission of the patient
to hospital.
Procedures
Diagnostic and therapeutic operations and procedures
carried out whilst an inpatient.
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References
1. Alfred Health. Alfred Casemix Clinical Handbook 10th Edition 2009 – 2010.
2009.
2. National Centre for Classification in Health (NCCH) – University of Sydney.
The Good Clinical Documentation Guide. 2003.
3. National Casemix Classification Centre. The International Statistical
Classification of Diseases and Related Health Problems, 10th Revision,
Australian Modification, 7th Ed, Version 1.1, Australian Coding Standards.
2010
4. Department of Health. Health Activity Purchasing Intentions 2012-2013.
Available from: http://activity/page/Publications.aspx.
5. Australian Medical Association. Safe handover: safe patients. Guidance on
clinical handover for clinicians and managers. Canberra: Australian Medical
Association; 2006.
6. Department of Health. Clinical Incident Management Policy: Using the
Advanced Incident Management System (AIMS). 2006: Available from:
http://www.safetyandquality.health.wa.gov.au/policies/index.cfm.
7. Department of Health and Ageing. Australian Refined Diagnosis Related
Groups, Version 6.0, Definitions Manual, Volume 1. 2008: Available from:
http://www.health.gov.au/internet/main/Publishing.nsf/Content/health-casemixardrg1.htm.
8. Porteous JM, Stewart-Wynne EG, Connolly M, Crommelin PF. iSoBAR--a
concept and handover checklist: the National Clinical Handover Initiative.
Med J Aust. Jun 1 2009;190(11 Suppl):S152-6.
9. Australian Commission on Safety and Quality in Health Care (ACSQHC).
The OSSIE guide to clinical handover improvement. Sydney: ACSQHC; 2010.
10. Department of Health. WA Sentinel Event Report 2010-2011. Available from:
http://www.safetyandquality.health.wa.gov.au/policies/index.cfm.
11. Independent Hospital Pricing Authority (2012). Independent Hospital Pricing
Authority National Efficient Price Determination 2012-2013, IHPA, Sydney.
Available at:
http://www.ihpa.gov.au/internet/ihpa/publishing.nsf/Content/home-1
59
iSoBAR
IDENTIFY
Introduce yourself (hospital, ward, role, job).
Introduce your patient (name, DOB, age, gender, location).
S
SITUATION
Why are you handing over? Briefly state the problem,
what, when, how severe?
o
OBSERVATIONS
Most recent vital signs and assessments*
BACKGROUND
Relevant information related to the patient:
• current relevant medications
• allergies
• IV fluids
• test results (date and time done, comparison
to previous results)
• resuscitation status
• relevant social information.
ASSESSMENT
What do you think is happening?
What is the problem (results of assessment, vital signs
and symptoms)?
AGREE A PLAN
What is your assessment of the situation?
What are you wanting (advice, orders, transfer)?
What is the level of urgency?
What is the plan?
READBACK
Clarify and check for shared understanding.
Who is responsible for what and by when?
READY FOR
DISCHARGE
What needs to be achieved for discharge and by whom?
Communicate the plan with the patient/carer and ward
clinical staff.
i
B
A
R
* Vital signs and assessments should be relevant to the profession handing over,
e.g. function level should be included for allied health professions; mental health
observations and behaviour for mental health professionals.
This document can be made available
Produced by ABF/ABM Team
© Department of Health 2012
HP012131 SEP’12
in alternative formats on request for
a person with a disability.

Clinical Casemix Handbook 2012-2014 Version 3.0

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