Clinical Documentation Tip Sheets

General 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).

CHRONIC CONDITIONS

> List all chronic conditions in the H&P and at least one progress note

> List all pertinent chronic conditions under the assessment & plan section with treatment, monitoring, or evaluation of each of the chronic conditions

> Diagnoses that are listed under the problem list can not be captured.

> Examples: CHF with chronicity and type, e.g., chronic diastolic heart failure continue metoprolol, COPD with chronic respiratory failure on home O2 on 2L NC, morbid obesity with BMI of 42; counseling, CKD stage 3a avoid nephrotoxic medications.

LAB ABNORMALITIES

> Always: check the lab

> Document: the lab abnormality as a diagnosis and the treatment, evaluation, or monitoring performed

> Example : hyponatremia Na 130 hold diuretics.

IMAGING REPORTS AND PATHOLOGY REPORTS > Remember to add to your notes the imaging reports and pathology reports and indicate the clinical significance of the findings

> Imaging and pathology reports diagnoses can not be captured unless added to treating provider notes.

> Example: chest x-ray shows clinically significant pleural effusion due to volume overload, increase dose of diuretics

UNCERTAIN DIAGNOSES > Include uncertain language to indicate your thought process and workup performed, e.g., chest pain rule out acute coronary syndrome; trend troponin, syncope suspected due to paroxysmal atrial fibrillation. > Clarify the uncertain diagnosis before discharge, e.g., syncope confirmed to be due to paroxysmal atrial fibrillation; rate control with Metoprolol and Eliquis for anticoagulation or acute coronary syndrome was ruled out with negative cardiac workup. > Add the diagnosis to your discharge summary if the diagnosis is still uncertain, e.g., lower GI bleed likely due to diverticulosis, F/U with GI to schedule colonoscopy as outpatient POA STATUS > Remember to add the POA status to acute or new diagnoses that were not documented on admission (in the H&P)