Clinical Documentation Tip Sheets

Emergency Medicine This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

SUPPORT THE MOST APPROPRIATE VISIT LEVEL

DOCUMENTATION TIPS

> Medical decision making dictates the highest level code that can be chosen. Proper documentation supports the chosen level (see MDM Tip Card) > Document all of the following: Chief complaint, primary diagnosis (or differential), secondary diagnoses (or chronic conditions that impact the care of the patient). > A diagnosis is required for every condition that is Monitored, Evaluated, Assessed OR Treated (MEAT). See HCC Tip Card. > Diagnoses cannot be inferred from physician orders, lab or diagnostic test results; diagnoses need to be in the medical record. > Under the assessment and plan section: document your list of diagnoses with MEAT criteria when applicable. > Consistent documentation: make sure no contradicting information in your note, for example: A&P: “Occasional dysphagia-worse with solids. Review of systems: ENT: denies sore throat, dysphagia. > Document: "if known” risk of morbidity/mortality associated with the diagnosis. > Document: if the condition is resolved in the ED, need further treatment after admission or follow up as outpatient.

> Level 1: Self-limited or minor: a problem that is transient and is not likely to permanently alter the patient’s health status or has a good prognosis with management/compliance. > Level 2: Low severity: a problem in which the risk of morbidity without treatment is low, there is little to no risk of mortality without treatment. Requires straightforward medical decision making. > Level 3: Moderate severity : a problem in which the risk of morbidity and mortality without treatment is moderate, or there is an uncertain prognosis or increased probability of prolonged functional impairment. Requires low medical decision making. > Level 4: High severity, requires urgent evaluation but does not pose threat to life or physiologic function: A problem in which the risk of morbidity and mortality without treatment is high to extreme, or a high probability of severe, prolonged functional impairment. Requires moderate medical decision making. > Level 5: High severity, poses an immediate significant threat to life or physiologic function: same las level 4. Requires high medical decision making. > Critical care level: level 5 + at least one organ system failure + at least 30 minutes of care: Examples of organ system failure: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. Requires high medical decision making.

> Document: decision to admit with medical necessity rationale (see MN Tip Card)