CDI 2

From a legal perspective, it’s crucial to document relevant clinical findings, detail the record of decisions made, actions agreed upon, and outline the proposed treatment plan, all of which are often encapsulated in consult notes.
Subjective

The patient’s account of their condition, often detailed in the HPI (History of Present Illness) section of a SOAP note, should be expressed in their own words. It’s important to include the chronology, quality, and severity of the symptoms, as well as details on the onset, to accurately reflect the hpi and history of present illness.

Objective

In the Objective section of your SOAP documentation, record measurable facts about the patient’s status, such as vital signs, observations, results from the physical exam findings, and any pertinent lab results. These objective data are critical for a comprehensive clinical assessment.

Assessment

Your primary medical diagnosis or interpretation of the data should be included in the Assessment section, based on the subjective and objective information gathered. This is a critical part of clinical reasoning and diagnoses, which informs the subsequent steps in patient care.

Plan

Finally, outline a specific treatment plan in your SOAP note documentation, detailing the actions taken or to be taken following the consultation, which may include medications, procedures, referral, or education. This treatment plan is essential for guiding patient care and ensuring continuity.
Chief Complaint should consist of a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient's words.
Complete procedure documentation
Avoid documenting in purely descriptive terms  (i.e. Elevated, Low, High)
Specify medical diagnoses when you are able • Acuity (i.e. Acute, Chronic, Acute on Chronic) • Type (i.e. Systolic or Diastolic) • Stages of disease or wounds • If it's a broad diagnosis like “Anemia” be sure to document the cause (i.e. Acute Blood Loss, Dilutional, Chronic Disease Related)
Include all diagnoses at the time of discharge even if resolved or unconfirmed but treated, evaluated, or monitored – Clarify after testing, any “suspected” diagnoses that are eliminated • Respond to queries on findings from pathology or autopsy reports • There should be no conflicting information between providers or services • New information should not be introduced in the DC summary
Chronic Medical Conditions  (Examples: CKD, CHF, DM, HTN, Chronic Respiratory Failure) – Did you draw labs that monitor a chronic condition? – Did you give a home medication for a chronic condition? – Did the patient require more nursing care?  (Examples: Bariatric, Elderly, Psychiatric cases) – Did the patient require a longer length of stay due to a chronic condition?  If you did the work, document it!
Documenting Malnutrition  The dietician's assessment will list a recommended malnutrition diagnosis based on ASPEN criteria. Possible conditions are as follows:   Mild (non-severe) malnutrition – First degree (ICD10: E44.1)   Moderate (non-severe) malnutrition – Second degree (ICD10: E44.0)   Severe protein calorie malnutrition- Third degree (ICD10: E43)   The malnutrition diagnosis must be documented by the provider, including how the specific type of malnutrition was monitored, evaluated, or treated. The diagnosis cannot be coded without this information.
For inpatients (not outpatients):
• Probable
• Possible
• Suspected
• Likely
• Still (yet) to be ruled out
How Sick Are Your Patients? • Not Sick = No Severity of Illness (SOI) or Risk of Mortality (ROM)  • Sick = One or more CC's (Complications/Comorbidities)  • Very Sick = One or more MCC's (Major Complications/Comorbidities)
Every condition that is documented as a secondary diagnosis in problem lists or progress notes needs supporting documentation on how it is being: – Monitored – Evaluated – Treated  • Regardless of clinical significance--we need to document anything that's treated, evaluated, monitored, increases LOS, or RN workload
Accurate Documentation Drives ... • Accurate reflection of patients' Severity of Illness (SOI)  • True indication of Risk of Mortality (ROM)  • Appropriate hospital and physician public profiles  • Reduction in denials for medical necessity or reimbursement  issues  • Appropriate hospital reimbursement
When documenting fractures, include the following parameters:  – Type e.g. Open, closed, pathological, neoplastic disease, stress – Pattern e.g. Comminuted, oblique, segmental, spiral, transverse – Etiology to document in the external cause codes – Encounter of care E.g. Initial, subsequent, sequelae – Healing status, if subsequent encounter e.g. Normal healing, delayed healing, nonunion, malunion – Localization e.g. Shaft, head, neck, distal, proximal, styloid – Displacement e.g. Displaced, non displaced – Classification e.g. Gustilo-Anderson, Salter-Harris – Any complications, whether acute or delayed e.g. Direct result of trauma sustained • In addition, depending on the circumstances, it may be necessary to document intra-articular or extra-articular involvement. For certain conditions, the bone may be affected at the proximal or distal end. Though the portion of the bone affected may be at the joint at either end, the site designation will be the bone, not the joint.
When documenting arrhythmias, include the following:  – Location e.g. Atrial, ventricular, supraventricular, etc. – Rhythm name e.g. Flutter, fibrillation, type 1 atrial flutter, long QT syndrome, sick sinus syndrome, etc. – Acuity e.g. Acute, chronic, etc. – Cause e.g., Hyperkalemia, hypertension, alcohol consumption, digoxin, amiodarone, verapamil HCl
When documenting heart valve disease, include the following: – Cause e.g. Rheumatic or non-rheumatic  – Type e.g. Prolapse, insufficiency, regurgitation, incompetence, stenosis, etc. – Location E.g. Mitral valve, aortic valve, etc.
When documenting atherosclerotic heart disease with angina pectoris, include the following: – Cause Assumed to be atherosclerosis; notate if there is another cause – Stability e.g. Stable angina pectoris, unstable angina pectoris – Vessel Note which artery (if known) is involved and whether the artery is native or autologous  – Graft involvement If appropriate, whether a bypass graft was involved in the angina pectoris diagnosis; also note the original location of the graft and whether it is autologous or biologic
When documenting cardiomyopathy, include the following, where appropriate: – Type e.g. Dilated/congestive, obstructive or nonobstructive hypertrophic, etc.  – Location e.g. Endocarditis, right ventricle, etc.  – Cause e.g. Congenital, alcohol, etc. List cardiomyopathy seen in other diseases such as gout, amyloidosis, etc.
When documenting CHF, include the following: – Acuity e.g. Acute, chronic – Type e.g. Systolic, diastolic
When documenting bronchitis and bronchiolitis, include the following: – Acuity e.g. Acute, chronic, subacute Delineate when both acute and chronic are present, e.g., acute and chronic bronchitis – Causal Organism e.g. Respiratory syncytial virus, metapneumovirus, unknown, etc.
When documenting otitis media, include the following: – Type e.g., Serous, sanguinous, suppurative, allergic, mucoid – Infectious agent e.g., Strep, Staph, Scarlett Fever, Influenza, Measles, Mumps – Temporal factors Acute, subacute, chronic, recurrent – Side e.g. Left, right or both ears – Tympanic membrane rupture Note whether this is present – Secondary causes e.g. Tobacco smoke, etc.
When documenting asthma, include the following: – Cause Exercise induced, cough variant, related to smoking, chemical or particulate cause, occupational – Severity Choose one of the three options below for persistent asthma patients – Mild persistent – Moderate persistent – Severe persistent – Temporal factors Acute, chronic, intermittent, persistent, status asthmaticus, acute exacerbation
When documenting abdominal pain, include the following: – Location e.g. Generalized, Right upper quadrant, periumbilical, etc. – Pain or tenderness type e.g. Colic, tenderness, rebound
When documenting injuries, include the following: – Episode of Care e.g. Initial, subsequent, sequela  – Injury site Be as specific as possible – Etiology How was the injury sustained (e.g. sports, motor vehicle crash, pedestrian, slip and fall, environmental exposure, etc.)? – Place of Occurrence e.g. School, work, etc. • Initial encounters may also require, where appropriate: – Intent e.g. Unintentional or accidental, self-harm, etc. – Status e.g. Civilian, military, etc.
When documenting hypertension, include the following:  – Type e.g. essential, secondary, etc. – Causal relationship e.g. Renal, pulmonary, etc.
1. ) Type 1 or Type 2 , due to underlying condition, gestational, drug or chemical induces – 2.) Complications – what if any other body system is involved or affected by the diabetic condition (e.g. foot ulcer related to diabetes type 2) – 3.) Treatment -  is the patient on insulin?
When documenting underdosing, include the following: – Intentional, unintentional, non compliance, reason? Is the underdosing deliberate (e.g. patient refusal)? – Why is the patient not taking the medication? (financial hardship, age-related debility)
patient’s condition. • Pain: • When documenting pain, include the following: – 1) acuity (e.g. acute or chronic – 2) location
Important items for the medical record – Document all of the patient’s existing health conditions  – All chronic conditions must be documented and reported
Documentation must include at least one of the criteria for each diagnosis submitted from the M.E.A.T. concept: that the condition was either −  Monitored – signs, symptoms, disease progression, disease regression −  Evaluated – test results, medication effectiveness, response to treatment −  Assessed – ordering tests, discussion, review records, counseling −  Treated – medications, therapies, other modalities
General Documentation/Coding Tips: History of  History of • History of means the patient no longer has this condition • History of conditions often appear in the record’s PMH • Frequent documentation errors regarding use of History of: – Coding a past condition as active – Coding History of when condition is still active  • Condition must be active on DOS in order to code  Incorrect Documentation Correct Documentation H/O CHF, meds Lasix Compensated CHF, stable on Lasix H/O angina, meds Nitroquick Angina, stable on Nitro H/O COPD, meds Advair COPD controlled with Advair
include all documentation if possible, including all General Practitioner notes, clinic lab results and test results, hospital and specialist notes.
Avoid unnecessary comments and vague comments, For example, do not write “no change” – specify the factors related to the patient’s condition that haven’t changed. Do not include inappropriate and irrelevant information, which could result in damaging legal action.
Providers would be well-served to document all patient encounters as though anticipating litigation. Providers should ask themselves: What information would be considered essential in a malpractice suit? How would we defend ourselves against negligence? Then document all cases accordingly.
documentation of active treatment for the condition. This applies even when the patient had surgery to remove the cancer but is still receiving treatment for the disease, such as antineoplastic medications, chemotherapy, radiotherapy, etc. As long as the patient continues to receive such treatment, the patient's cancer should be coded as a current, active disease condition
document the condition and its medical significance
Document and code for any use or exposure to tobacco. Should only be assigned if physician documentation states condition is due to exposure. (Do not assign as primary diagnosis).
Focus clinical documentation on the severity of asthma and relationship to other diseases when applicable
If causative organism is known and documented, code specified organism
the medical record documentation must present a specific causal relationship between the two conditions.

Examples of such a causal relationship include: “with, in related to, related with
Remember, if a condition has been:

Monitored (signs, symptoms, improvement/worsening of condition);

Evaluated (test results, medication effectiveness, response to treatment);

Assessed (ordering tests, review records, counseling) and/or;

Treated (medications, therapies, other treatments/procedures), the condition should be coded and reported on the claim.
Document the diagnosis of cachexia, underweight, overweight, obesity, or morbid obesity when applicable. 
 
BMI            Weight Status
  <18.5        Underweight
  18.5 to 24.9      Normal/Healthy
  25 to 29.9      Overweight
  30 to 39.9      Obesity
  >40           Extreme Obesity (Morbid)
 
Key Concepts:

When applicable, document “Cachexia, Underweight, Overweight, Obesity, Morbid Obesity” in your assessment and plan. These diagnoses need to be documented by the provider to capture the BMI, although the BMI itself does not need to be documented by the provider 
Correlate your physical exam to these diagnoses. A cachectic or underweight patient is not “well developed and well nourished.”
Descriptive findings stated in the physical exam cannot be coded unless the provider further documents the condition as a medical diagnosis. Common descriptive examples: cachectic, obese, malnourished, etc. 
BMI impacts comorbid conditions and may affect overall health status, which is why a CDS or Coder might query the provider.

Document using the proper medical terminology such as “hypo” or “hyper”, instead of low or high
 
Document cause of anemia d/t acute blood loss, specific chronic disease, meds (chemo)
 
Document clinically significant abnormal Lab Findings, outside of the BJC Standard Reference Range, and is being monitored, treated, or evaluated.
 
Lactic acidosis is frequently over -documented. BJC guidelines consider lactic acidosis with a lactate level > 4 mmol/L. Less extreme lactate elevation is referred to as hyperlacticemia >2 mmol/L
 
Do not document hyperkalemia or hyponatremia if the lab value is felt to be reflective of pseudo-hyperkalemia or pseudo-hyponatremia 
Add any query response diagnosis into the Assessment/Plan of subsequent progress notes to reflect accurate documentation of the patient’s condition and to ensure continuity of documentation.
Specify a diagnosis that reflects the patient's level of strength and mobility on admission, and document in the medical record and
on the form below.
Specify a diagnosis that accurately reflects the lab findings, and
document in the medical record and on the form below.
Specify a diagnosis that accurately reflects the lab findings, and
document in the medical record and on the form below.

Specify a diagnosis that accurately reflects the lab findings, and
document in the medical record and on the form below.