Clinical Documentation Improvement Program

The Clinical Documentation Specialists (CDS) have been at WellStar Kennestone Hospital for a year now and we have seen great improvements in the way physicians have been documenting thus far.  With that said, there is always room for improvement to help us accurately capture severity of illness and risk of mortality.

The CDS team noticed certain trends that affect whether or not a condition or diagnosis can be captured during the final coding phase.  For instance, the term “versus” is being documented to describe the differential diagnosis when the patient has a symptom.  For example: the patient comes to the ER with a fever.  Fever secondary to UTI vs. sepsis are mentioned in the progress notes.  When this chart eventually goes to coding, the coder has to pick up the fever (symptoms) as the admitting diagnoses because “versus” was used to describe the possible causative diagnoses; this is true even if the treatment plan supports those diagnoses describe with the term versus.  The solution to this conundrum is to precede each differential diagnosis/suspected diagnosis with “rule out.”  For example: fever secondary to r/o UTI, r/o sepsis.  When the chart is coded, both UTI and sepsis may be used as diagnoses unless they were specifically mentioned as being ruled out or the treatment plan doesn’t support the diagnosis.

Sometimes the patients are admitted and the physicians cannot 100 percent determine what is causing the patients’ symptoms, although they have a pretty good idea what it may or may not be. If you are treating a condition, it is acceptable to use the terms “likely, probably, possibly, and questionable” when documenting diagnoses. This captures SOI and ROM; the regulations allow documentation based on resource consumption. This is permissible only in the hospital inpatient setting.

CDS is located in the Medical Records Department and Hospitalist office on the lower level of WellStar Kennestone Hospital.  We are here to bridge clinical thought processes into coding language and to facilitate accurate documentation.

Office number: 770-793-5294.