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 Respiratory-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:

• Clarification by the attending is necessary when there is conflicting or inconsistent documentation in the medical record. (i.e., 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.

Respiratory-Specific Tips:

• Respiratory failure diagnosis: Differentiate if condition is acute respiratory failure or chronic respiratory failure
• If a chronic condition requires admission for treatment, clarify if it is an acute event or exacerbation of chronic condition
• Clarify causative organism of pneumonia (i.e., gram negative, MRSA, pseudomonas, fungus or if aspiration pneumonia)
• Provide most specific diagnosis/condition causing a symptoms (i.e., hypoxia, dyspnea, respiratory distress or hemoptysis)
• Cor pulmonale: Clarify acute or chronic
• Clarify if an evolving diagnosis/condition was present on admission, if after further study it is documented later in the stay
• If diagnosis of end stage COPD and/or O2 dependent, clarify if it is chronic respiratory failure

Clinical Documentation Tip: Malnutrition Documentation

When you find a query that includes clinical descriptions of nutritional status (Nutrition assessment, albumin, prealbumin, protein levels, treatment such as TPN, Ensure Megace and descriptors i.e. cachexia, anorexia and BMI < 19), Clinical Documentation RNs are inquiring if you are treating, monitoring and evaluating the diagnosis of malnutrition (protein/calorie) and are asking for that to be documented along with a degree of severity (mild, moderate or severe).

Clinical Documentation Tip: Documenting Anemia

It’s critical to properly document Anemia to capture your patient’s severity of illness:

Clinical documentation Tip: Renal Status

This month’s “hot topic” from clinical documentation is renal status.  Acute renal insufficiency does not capture your patient’s severity of illness.  Renal insufficiency typically refers only to mild kidney dysfunction.  Renal insufficiency and A/CKD are not synonymous with Acute Kidney Injury or Failure; please do not use these terms interchangeably.

Physician Documentation Tip: Pneumonia

Clinical documentation is required to be compliant with Medicare and other regulatory standards for accurate coding and to reflect the overall severity/acuity of illness and risk of mortality. Below are some important key elements to keep in mind when documenting the diagnosis of pneumonia.