WellStar Health System’s Gold Standards of Clinical Documentation Improvement

General and Surgery-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:

• Queries may be responded to by the attending physician, consultants or advanced practice professionals; however, it is ultimately the attending physician’s responsibility
• Consider SIRS and indicate if the cause is related to infection, trauma, burns or pancreatitis

Surgery-Specific Tips:

• Always document acuity, even when it is obvious. State acute, chronic, acute on chronic when known. Example: acute on chronic cholecystitis, acute blood loss anemia, chronic pancreatitis
• Document all co-existing medical conditions, as this will impact the severity of illness level for your patients. Example: Diabetes, Chronic CHF
• Trauma: List injuries separately when describing multiple trauma. Document any loss of consciousness and the duration.
• Fractures: Document traumatic versus pathological, with identification of underlying cause
• Debridement: Always document excisional versus non-excisional, the depth of tissue removed and the method (Versajet, scalpel, etc.)
• Document pathology findings within progress notes or discharge summary
• Document a diagnosis, such as hyponatremia, rather than ↓NA. Up and down arrows are not acceptable for coding purposes.
• Link any conditions to underlying cause. Example: Skin ulcer due to DM, gastroparesis due to DM