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)

WellStar Health System’s Gold Standards of Clinical Documentation Improvement

General and Gastrointestinal-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:

• 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).

Gastrointestinal (GI)-Specific Tips:

• Diagnoses: indicate if acute or chronic
• Link diagnosis with manifestations (i.e., acute hepatitis C with hepatic coma)
• GI bleed: indicate if with or without hemorrhage, even if suspected because no longer bleeding at time of scope
• Link ulcer: indicate if with or without hemorrhage, obstruction or perforation
• Link ulcer with site: esophageal, peptic, duodenal. Be as specific as possible.
• Specify location of calculus (i.e., gallbladder, bile duct, etc.)
• Esophageal varices: link underlying condition, if known (i.e., cirrhosis, portal hypertension)
• Gastroenteritis: identify infectious organism (i.e., candida, bacterial, virus)
• Alcohol-related conditions: (i.e., dependence, abuse/chronic, withdrawal delirium, delirium tremens, withdrawal) OR current alcohol state: alcoholism, abuse or history of
• Electrolyte imbalance (i.e., hyper/hyponatremia, hyper/hyp kalemia, acidosis, alkalosis, mixed acid base balance disorder)
• Nutritional state: if malnourished, indicated mild, moderate or severe or cachexia
• Hemorrhage/bleed: indicate if acute or chronic
  
  ***GI bleed/hemorrhage is not synonymous with acute blood loss anemia***

WellStar Health System’s Gold Standards of Clinical Documentation Improvement

General and Surgery-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:

• Queries may be responded to by the attending physician, consultants or advanced practice professionals; however, it is ultimately the attending physician’s responsibility
• Consider SIRS and indicate if the cause is related to infection, trauma, burns or pancreatitis

Surgery-Specific Tips:

• Always document acuity, even when it is obvious. State acute, chronic, acute on chronic when known. Example: acute on chronic cholecystitis, acute blood loss anemia, chronic pancreatitis
• Document all co-existing medical conditions, as this will impact the severity of illness level for your patients. Example: Diabetes, Chronic CHF
• Trauma: List injuries separately when describing multiple trauma. Document any loss of consciousness and the duration.
• Fractures: Document traumatic versus pathological, with identification of underlying cause
• Debridement: Always document excisional versus non-excisional, the depth of tissue removed and the method (Versajet, scalpel, etc.)
• Document pathology findings within progress notes or discharge summary
• Document a diagnosis, such as hyponatremia, rather than ↓NA. Up and down arrows are not acceptable for coding purposes.
• Link any conditions to underlying cause. Example: Skin ulcer due to DM, gastroparesis due to DM

WellStar Health System’s Gold Standards of Clinical Documentation Improvement

General and Nephrology-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:

• 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 controlled DM or heart failure caused by hypertension).
• Urosepsis is a nonspecific term, document UTI only, or sepsis due to UTI, as appropriate.

Renal:

• AKI: Clarify if this is acute kidney injury or acute kidney insufficiency.
• ARI or acute renal insufficiency is not interchangeable with acute kidney injury or failure. Clarification will be sought when both are documented in the record.
• Clarify the abbreviation of A/CKD. Acute kidney disease is non-specific, please specify as acute insufficiency or acute injury.
• Document underlying cause of acute kidney injury or acute renal failure, if known.
• Remember to document ATN when appropriate.
• Clarify stage and underlying cause of chronic kidney disease (i.e. CKD III due to diabetes).
• Document linkage when a UTI is related to a foley or suprapubic catheter.

WellStar Health System’s Gold Standards of Clinical Documentation Improvement

General and Neurology-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

• Indicate acuity, even when it is obvious, i.e. congenital, chronic, acute, acute or 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.

Neurology

• Altered mental status: Clarify if related to encephalopathy, dementia with acute confusional state, acute delirium/dementia.
• Link late effect to CVA, if appropriate, i.e. dysphagia, hemiplegia.
• Dementia: Indicate if presenile or senile and whether it is related to delirium, delusional features or depressive features.
• Dementia: Indicate behavioral disturbance i.e. aggressive, combative, violent or wandering.
• TIA:  Clarify cause i.e. arrhythmia, carotid artery occlusion, electrolyte imbalance, CVA, DM. 

CDI

WellStar Health System’s Gold Standards of Clinical Documentation Improvement

General and Infectious Disease 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

• Document every condition that impacts the patients care, including chronic conditions.
• Document the diseases associated with the patient’s signs/symptoms.  

Infectious Disease Tips:

• Bacteremia is defined as a non-specific laboratory finding of bacteria in the blood with no signs of illness.
• Bacteremia and sepsis are not considered synonymous terms.
• Sepsis is SIRS due to an infection (An infection-introduced syndrome in the presence of two or more manifestations of SIRS without organ dysfunction).
• In cases of severe sepsis, identify the affected organs when known.
• Identify the source of the infection or trauma that is responsible for SIRS (e.g. sepsis or SIRS), secondary to pneumonia.

Definition of terms:

• Bacteremia: Nonspecific laboratory finding of bacteria in the blood
• Septicemia: Systemic disease associated with the presence of pathogenic organisms in the blood
• Sepsis:  An infection-induced syndrome without organ dysfunction
• Sever Sepsis: Sepsis with associated acute organ dysfunction
• Septic Shock:  Severe sepsis in which the cardiovascular system begins to fail, blood pressure drops and vital organs are deprived of adequate blood supply.
• SIRS: Systemic Inflammatory Response Syndrome refers to systemic response to            infection, trauma, burns or other insults. Criteria for SIRS include meeting two or more of   the following:
• Fever > 100.4 F or hypothermia < 96.8 F
• Leukocytosis - WBC >12,000 or leukopenia WBC < 4,000 or > 10 percent    bands
• Tachycardia- > 90 beats/minute

Celebrating National Clinical Documentation Improvement Week (Sept. 18-24)

WellStar Cobb Hospital Clinical Documentation Specialists with hospitalist, Dr. Hindi.

WellStar Kennestone Hospital Clinical Documentation Specialists with (2nd from left) Dr. Ricky Washington, hospitalist; (3rd from left) Sheri Chazen, PAC, Urology Associates and (4th from left) Dr. Beau Dusseault, Urology Associates.

WellStar Kennestone, Cobb and Douglas Hospitals’ medical staff celebrated the Association of Clinical Documentation Specialist’s first annual Clinical Documentation Improvement Week with snacks and clinical documentation improvement tips offered by WellStar’s Clinical Documentation Specialists.

Clinical Documentation Specialists are part of the WellStar Health System’s Clinical Documentation Improvement (CDI) Program, which 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.
Coding rules and regulatory requirements often differ from the way physicians are trained to document their clinical thought processes. Clinical documentation specialists are knowledgeable in interpreting physician documentation and can identify opportunities to bridge the differences between clinical language and coding terms. The CDI professional works to facilitate the overall quality and completeness of clinical documentation to accurately represent the severity, acuity and risk of mortality profile of the patient being treated.

WellStar Health System’s Gold Standards of Clinical Documentation Improvement
As part of the program’s ongoing efforts, the CDI team will be providing monthly general and body system specific tips from the Program’s Gold Standards of Clinical Documentation Improvement in this and future issues of Medical Staff News.

Tips of the Month:
General:

• 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

Circulatory system:

• CHF: clarify type and acuity: acute, chronic or acute on chronic along with diastolic, systolic or combined
• Cardiomyopathy documented with EF is not synonymous with heart failure in coding terms
• Hypertension: please clarify as accelerated or malignant when present
• Angina clarify cause when known or suspected such as: post MI syndrome, progressing CAD, Prinzmetal, Accelerated or Dressler’s syndrome
• Chest pain indicate likely underlying cause i.e cardiac arrhythmia, pleuritc, GERD, CAD, psychogenic

If you have questions or need more information about the CDI Program, please contact:

Katrina Allen, Supervisor, Clinical Documentation Improvement, WellStar Kennestone and Douglas Hospitals: (770) 842-9731 or Katrina.allen@wellstar.org
or
Darcee Sellari, Supervisor, Clinical Documentation Improvement, WellStar Cobb Hospital: 770-842-1299 or darcee.sellari@wellstar.org

Clinical Documentation Improvement Program Ensures Accurate Data Reporting

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.
Accurate data reporting is also critical in the current era of increased public scrutiny of healthcare in general. A hospital’s coded data communicates to consumers the organization's quality, experience and overall outcomes. Consumers have unlimited data resources available to assist them when choosing a provider or hospital for their medical needs. The National Committee for Quality Assurance Physician and Hospital Quality Report Card, Healthgrades and RateMDs.com are just a sampling of these. WellStar hospitals are reimbursed for the care they provide through accurate coding, and accurate coding depends upon accurate documentation in the medical record.

How does the CDI Program work?

The CDI Program employs clinical documentation specialists, who review medical record documentation during a patient’s hospital stay. Coding rules and regulatory requirements often differ from the way physicians are trained to document their clinical thought processes. Clinical documentation specialists are knowledgeable in interpreting physician documentation and can identify opportunities to bridge the differences between clinical language and coding terms. The CDI professional works to facilitate the overall quality and completeness of clinical documentation to accurately represent the severity, acuity and risk of mortality profile of the patient being treated.

“The premise of the CDI Program is to ensure that the documentation most accurately reflects the clinical condition of the patient,” said Kelli Williams, executive director, WellStar Clinical Documentation Improvement and Coding Services. “The information collected for reporting and reimbursement purposes are gleaned by a complete review of the patient’s chart,” she said. “Thorough documentation of the treatment of our patients, their diagnoses and procedures is necessary to insure that the data we collect is as accurate as can be.”

The CDI Program is currently in place at WellStar Cobb, Douglas and Kennestone hospitals. Plans call for it to be expanded to WellStar Paulding Hospital sometime in the future.