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 diseases associated with the patient’s signs/symptoms
- Indicate acuity, even when it is obvious (i.e., congenital, chronic, acute, acute on chronic [exacerbation])
- Clarify the reason requiring inpatient admission (i.e., diagnosing, treatment or staging of malignancy)
- Clarify if the reason for admission is a sign/symptom that is due to the malignancy (i.e., dehydration, malnutrition, cachexia, intractable pain, ascites, anemia or weakness)
- Clarify malnutrition, indicating acuity (i.e. mild, moderate or severe)
- Clarify anemia, indicating if it is associated or due to chemotherapy, immunotherapy or radiation therapy
- Clarify any coagulation disorders as well as the cause
- Clarify if thrombocytopenia, pancytopenia or anemia is induced by malignancy or treatment of malignancy (i.e., chemotherapy induced)
- Clarify if fractures are a result of the malignancy (i.e., due to neoplasm)
- Clarify any electrolyte abnormality (i.e., hyponatremia, hypokalemia [up and down arrows plus corresponding electrolyte does not constitute a diagnosis])
- Clarify all secondary diagnoses, indicating if condition is acute or chronic during current admission
- Clarify all diagnoses/conditions that are present on admission (POA)
- Clarify if the patient is placed in palliative care (i.e., hospice care, terminal care, comfort care or end-of-life care)
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