Clinical Documentation Tip Sheets

Welcome

PHYSICIAN ADVISOR PROGRAM

This tip sheet series is designed to support physicians in accurately assessing, diagnosing, and documenting the severity of illness for hospitalized patients within the electronic medical record (EMR). Comprehensive and condition-specific, these guides aim to enhance clinical clarity, ensure proper coding, and support the justification for medical necessity and appropriate level of care. By aligning documentation practices with current clinical and coding standards, providers can optimize communication, compliance, and quality outcomes.