WellStar Health System’s Gold Standards of Clinical Documentation Improvement

General and Endocrine-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:

• Clearly document the patient’s “reason/diagnosis for admission.”
• If the patient’s reason for admission is a symptom, document the likely cause including probable, possible, suspected or differential diagnoses.

Endocrine-Specific Tips:

• When diabetes mellitus is documented, additional documentation is necessary (i.e., Type I versus Type II, uncontrolled versus controlled diabetes and any manifestations associated, if any).
• Documentation of “out of control” diabetes is assigned to uncontrolled.
• Documentation of “poorly controlled” and “inadequately controlled” cannot be captured.
• If a diabetic condition, or a condition due to the diabetes, necessitated the admission, the cause and effect relationship between the manifestation and diabetes must be documented.
• Diabetic manifestations:
        Neurological manifestations:
              DM neuropathy
              DMN with ulcers
              DMN with impotence
              DMN with foot drop
              DMN with gastroparesis
              Autonomic neuropathy

                Ophthalmic manifestations:
                      Retinopathy
                      Blindness
                      Cataracts
                      Glaucoma

                Diabetic peripheral manifestations:
                      DM PVD
                      DM PVD with ulcers
                      DM gangrene

                Diabetic renal manifestations:
                     DM nephropathy
                     DM nephropathy with renal insufficiency
                     DM nephropathy with chronic renal failure
                     DM nephropathy with nephritic syndrome
                     DM nephropathy with ESRD and hypertension

               Other manifestations:
                    Diabetic cellulitis
                    Diabetic ulcers (not PVD or neuropathy)
                    Diabetic bone changes
                    Diabetic osteomyelitis
                    Diabetic hypoglycemic with coma
                    Diabetic hypoglycemia without coma
                    Diabetic coma with ketoacidosis
                    Diabetic coma, nonketotic
                    Diabetic ketoacidosis without coma
                    Diabetic NKHHC (hyperosmolarity)
                    Diabetic impotence (not neuropathy)