CDI

WellStar Health System’s Gold Standards of Clinical Documentation Improvement

General and Infectious Disease Clinical Documentation Tips

 WellStar Health System’s Clinical Documentation Improvement (CDI) Program is designed to ensure that clinical documentation in a patient’s medical record appropriately reflects the care provided. The most vital role of the CDI program is facilitating a true representation of healthcare services provided, through accurate reporting of the principal diagnosis, co-morbidities and any treatments or procedures.

As part of the program’s ongoing efforts, the CDI team offers specific tips monthly from the Program’s Gold Standards of Clinical Documentation Improvement.

General Tips

• Document every condition that impacts the patients care, including chronic conditions.
• Document the diseases associated with the patient’s signs/symptoms.  

Infectious Disease Tips:

• Bacteremia is defined as a non-specific laboratory finding of bacteria in the blood with no signs of illness.
• Bacteremia and sepsis are not considered synonymous terms.
• Sepsis is SIRS due to an infection (An infection-introduced syndrome in the presence of two or more manifestations of SIRS without organ dysfunction).
• In cases of severe sepsis, identify the affected organs when known.
• Identify the source of the infection or trauma that is responsible for SIRS (e.g. sepsis or SIRS), secondary to pneumonia.

Definition of terms:

• Bacteremia: Nonspecific laboratory finding of bacteria in the blood
• Septicemia: Systemic disease associated with the presence of pathogenic organisms in the blood
• Sepsis:  An infection-induced syndrome without organ dysfunction
• Sever Sepsis: Sepsis with associated acute organ dysfunction
• Septic Shock:  Severe sepsis in which the cardiovascular system begins to fail, blood pressure drops and vital organs are deprived of adequate blood supply.
• SIRS: Systemic Inflammatory Response Syndrome refers to systemic response to            infection, trauma, burns or other insults. Criteria for SIRS include meeting two or more of   the following:
• Fever > 100.4 F or hypothermia < 96.8 F
• Leukocytosis - WBC >12,000 or leukopenia WBC < 4,000 or > 10 percent    bands
• Tachycardia- > 90 beats/minute