Wednesday, September 14, 2016

Tips for Great Clinical Documentation Part 3

In the previous post of the series, I outlined the importance of using the terms “probable”, “possible”, “likely” and “not ruled out” when documenting in a medical chart. In this post I am going to highlight the importance of being consistent with the diagnoses throughout the duration of the record.

Be consistent with diagnoses throughout the record.

In clinical practice, a provider, as seen in the previous post, can make decisions and place orders based on a probable diagnosis. As the days pass and more clinical data is available, most of those diagnoses will be clarified and the decision-making might change or remain the same. For this reason, it is important to document what happened with the initial “probable” diagnosis. The use of the term “ruled out” is very useful because it tells the coder that what we initially thought was probable, it is not a possibility anymore. In a case of “probable pneumonia” in the first day, the record may read on the second day: “Pneumonia was ruled out”. This implies that antibiotics are not being used anymore, so the chart would reflect proper allocation of resources.

The other situation that needs to be taken into account is the one that results from the resolution of a problem. This is particularly important in prolonged hospitalizations, when problems that were there originally, end up being resolved. It is good practice to carry the diagnosis in the assessment section and document “resolved”. This has the added benefit of letting providers that  arrive later in the picture, that a patient had a problem and it is not present anymore. With respect to the allocation of resources, it is different to document “resolved” that to document “ruled out”. “Resolved” means that the problem was there and was corrected using the treatments ordered by the provided. “Ruled out” means that the problem was never there and any continued use of resources is not justified. A document may read like this: “Hyponatremia. Present on admission, resolved.”

Marco A. Ramos MD
Second Medical Opinions PLC

Physician Advisor in Clinical Documentation

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