WellStar Health System’s Gold Standards of Clinical Documentation Improvement

General and Respiratory-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:

• Clarification by the attending is necessary when there is conflicting or inconsistent documentation in the medical record. (i.e., attending physician documents bacteremia and consultant documents sepsis)
• Discharge summary: Include all the diagnoses that were clinically evaluated, therapeutically treated, diagnostically tested, or caused an increase in length of stay or nursing care throughout the patient’s stay.

Respiratory-Specific Tips:

• Respiratory failure diagnosis: Differentiate if condition is acute respiratory failure or chronic respiratory failure
• If a chronic condition requires admission for treatment, clarify if it is an acute event or exacerbation of chronic condition
• Clarify causative organism of pneumonia (i.e., gram negative, MRSA, pseudomonas, fungus or if aspiration pneumonia)
• Provide most specific diagnosis/condition causing a symptoms (i.e., hypoxia, dyspnea, respiratory distress or hemoptysis)
• Cor pulmonale: Clarify acute or chronic
• Clarify if an evolving diagnosis/condition was present on admission, if after further study it is documented later in the stay
• If diagnosis of end stage COPD and/or O2 dependent, clarify if it is chronic respiratory failure