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Documentation Tips

Posted on: June 1, 2018

Documentation Continuity

  • Any diagnosis/conditions that are being treated and/or monitored should be documented continuously throughout the medical records.

Example: Patient admitted with diagnosis of Sepsis due to Pneumonia and Acute Respiratory Failure. During the hospital stay, patient received initial treatment for these diagnoses. Once the patient is no longer receiving treatment     for Sepsis and Acute Respiratory Failure, documentation should reflect that the Sepsis and Acute Respiratory Failure – Resolved; but continue current antibiotic regimen for Pneumonia. (Brundagegroup, 10/2015)

  • When a query is answered by the physician, please remember to add this answer to your progress notes. This will ensure that any additional diagnosis/conditions that were queried are continued in the medical records and available to other physicians.

Discharge Summary

  • “The Discharge Summary is considered the final diagnostic statement of the entire hospitalization. Please include a complete list of every diagnosis or medical issue that impacted your patient’s care during their hospitalization.” (Brundagegroup, 2018)
  • “There should be no conflicting documentation between what is contained in the Discharge Summary and what has previously been documented in the rest of the medical records.” (Brundagegroup, 2019)

Linking Diagnosis/Conditions

  • The provider’s documentation must link the diagnosis/conditions in the medical records. Terms used to indicate diagnosis and condition links are as follows: with, associated with, in, and due to. (Pinson, R., Tang, C., 2018)

Examples:

UTI due to indwelling Foley catheter

Sepsis due to Pneumonia

 

Brundagegroup.com/wp-content/uploads/2018/Discharge-Summary-Importance.pdf

Brundagegroup.com/wp-content/upload/2015/10/Documentation-Continuity-1.pdf

Pinson, R., Tang, C. (2018) CDI pocketguide. P.44

 

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