WellStar Health System’s Gold Standards of Clinical Documentation Improvement

Clinical Documentation Tips: General and Specific for Blood Organs, Blood-Forming Organs and Immunological Disorders

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:

• Document the acute diagnoses present in the Emergency Department, even if improved, stable or resolved upon admission.
• Document every condition that is impacts the patients care, including chronic conditions.

Blood Organs, Blood-Forming Organs and Immunological Disorders:

• Clarify the type and/or cause of anemia (i.e., aplastic anemia, autoimmune hemolytic anemia, acute blood loss anemia).

• Clarify whether neutropenic fever, versus neutropenic sepsis.

• Anemia must be linked to condition, if cause is known (i.e., anemia in chronic kidney disease, anemia in neoplastic disease or anemia due to chemotherapy).

• If hemorrhagic disorder /coagulopathy is documented, please clarify if due to anticoagulants or a coagulation defect.

• Please do not use up and down arrow with a lab value if it is indicative of a diagnosis (i.e., down arrow platelets for thrombocytopenia).

• Many anemias are chronic conditions and do not require inpatient admission. If this is the reason for inpatient admission, please clarify after further study what diagnosis caused the admission.