WellStar Health System’s Gold Standards of Clinical Documentation Improvement

General and Neurology-Specific 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

• Indicate acuity, even when it is obvious, i.e. congenital, chronic, acute, acute or chronic (exacerbation).
• When radiology/pathology/laboratory findings are clinically significant they need to be referenced in the progress notes by a physician or mid-level provider.

Neurology

• Altered mental status: Clarify if related to encephalopathy, dementia with acute confusional state, acute delirium/dementia.
• Link late effect to CVA, if appropriate, i.e. dysphagia, hemiplegia.
• Dementia: Indicate if presenile or senile and whether it is related to delirium, delusional features or depressive features.
• Dementia: Indicate behavioral disturbance i.e. aggressive, combative, violent or wandering.
• TIA:  Clarify cause i.e. arrhythmia, carotid artery occlusion, electrolyte imbalance, CVA, DM.