WellStar Health System’s Gold Standards of Clinical Documentation Improvement

Review of General 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 general and specific tips monthly from the program’s Gold Standards of Clinical Documentation Improvement. 


This month, we include a review of general clinical Documentation 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
• Document the acute diagnoses present in the Emergency Department, even if improved, stable or resolved upon admission
• Document every condition that impacts the patients care, including chronic conditions
• 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])
• When radiology/pathology/laboratory findings are clinically significant they need to be referenced in the progress notes by a physician or mid-level provider
• Multi-organ failure: list organs separately, such as “acute respiratory failure” and “acute renal failure”
• Link disease processes as appropriate (i.e., PVD caused by uncontrolled DM or heart failure caused by hypertension)
• Queries may be responded to by the attending, consultants or mid-levels; however, it is ultimately the attending physician’s responsibility
• Coding rules disallow the use of up and Down arrows to indicate a diagnosis. (e.g.,  ↑K   cannot be used to code  hyperkalemia, the provider must Document the condition)
• When using abbreviations the diagnosis is best captured when the condition is written out in full at least one time in the record. (e.g., AKI could indicate Acute Kidney Injury or Acute Kidney Insufficiency) 
• Clarification by the attending is necessary when there is conflicting or inconsistent Documentation in the medical record. (e.g., 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.