Friday, July 15, 2016

Tips for Great Clinical Documentation Part 1.

As I explained in the previous post of the series, Clinical Documentation Improvement (CDI) is a recognized process of improving records to ensure improved patient outcomes, data quality and accurate reimbursement1. In order to achieve great documentation before the need for a Clinical Documentation Specialist (CDS) queries a medical provider, there are some tips that are usually useful. In this post I will present a few of these, with more tips coming in the next post.

Be Specific

By being specific I mean, to describe the condition as much as you can un terms that are accepted by all practitioners and coding specialists. For example, you should always indicate the stage of a condition, e.g, it is not enough to document chronic kidney disease (CKD) alone. It is important to say if this is a stage III, or a stage IV CKD. Treating a more severe condition, represents that more resources are being used because the patient is sicker. Also, the type of condition that the provider is dealing with is necessary to be known, for example, if the chronic heart failure is of a systolic type or a diastolic type. Treatment, may be different between those conditions and establishing the difference might have an impact in retrospective research. Finally, specifying the chronicity of an illness (acute or chronic) is important. An example of this is anemia. Having a hemoglobin concentration of 7.0 g/dL is different if this is a consequence of a gastrointestinal hemorrhage or if this is a level that has been maintained for years, like in patients with sickle cell anemia. The first patient will need a gastroenterology consultation with a possible endoscopic procedure, the second patient will need careful monitoring and possible advise from a hematologist.

Marco A. Ramos MD
Second Medical Opinions PLC
Physician Advisor in Clinical Documentation


1. Retrieved June 2, 2016

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