WellStar Health System’s Gold Standards of Clinical Documentation Improvement

General and Nephrology-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:

• Multi-organ failure: list organs separately, such as “acute respiratory failure” and “acute renal failure.”
• Link disease processes as appropriate (i.e. PVD caused by controlled DM or heart failure caused by hypertension).
• Urosepsis is a nonspecific term, document UTI only, or sepsis due to UTI, as appropriate.

Renal:

• AKI: Clarify if this is acute kidney injury or acute kidney insufficiency.
• ARI or acute renal insufficiency is not interchangeable with acute kidney injury or failure. Clarification will be sought when both are documented in the record.
• Clarify the abbreviation of A/CKD. Acute kidney disease is non-specific, please specify as acute insufficiency or acute injury.
• Document underlying cause of acute kidney injury or acute renal failure, if known.
• Remember to document ATN when appropriate.
• Clarify stage and underlying cause of chronic kidney disease (i.e. CKD III due to diabetes).
• Document linkage when a UTI is related to a foley or suprapubic catheter.