Tips for Great Clinical Documentation Part 2.

In the previous post of the series, I outlined the importance of being specific when documenting in a medical chart. In this post I am going to stress the importance of documenting uncertainty and how to use it to reflect decision making by a physician or advanced practice provider.

Terms like probable, possible, likely or “not ruled out” are acceptable

Many decisions that providers make when practicing medicine are not the direct result of knowing a diagnosis, but a logical decision based on a probability. A typical example of this is the treatment for “healthcare associated pneumonia” (HAP). First of all, just documenting HAP is not  enough for a coder. Here, the provider has to be specific, stating what is he or she treating. The problem arises when the specific bacteria that is causing the HAP is not known. A way to deal with this is to use the following rationale: It is known that is is highly likely that HAP could be caused by pseudomonas because of the exposures these kind of patients have had. For this reason, the provider can cover for that pathogen based on a high probability, not on a certainty.

The documentation may read as follows: “Healthcare Associated Pneumonia. Probable Pseudomonas. Covered with cefepime.” By documenting like this, the provider was specific, showed the seriousness of the condition and justified a use of resource based on a probability.

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation