Clinical Documentation Tip Sheets

Musculoskeletal

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).

FRACTURES

> Type: traumatic, stress, pathological, osteoporotic, etc.

> Location of the fracture

> Specify: displaced or non-displaced and closed or open

Tip: With traumatic fractures document contributing factors to the fracture if present, e.g., osteoporosis, osteomyelitis, neoplastic disease.

RHABDOMYOLYSIS

> Type: traumatic, non traumatic: metabolic, inflammatory, ischemic

> Document: associated AKI, ATN, electrolyte imbalance

MOBILITY ISSUES

Contractures, Debility, Assistance w/ daily activities, Assistance w/ movement, Functional Quadriplegia

FUNCTIONAL QUADRIPLEGIA > Definition: Functional quadriplegia is used to describe patients who are completely immobile for reasons other than an injury to the spinal cord. Per CMS, these patients are completely bedbound and dependent on others for all ADLs (feeding, grooming, turning, bathing, etc.)

Tip : Complete immobility codes to functional quadriplegia

CRITICAL ILLNESS MYOPATHY AND POLYNEUROPATHY

Definition: CIM: Flaccid weakness, often accompanied by difficulty weaning from mechanical ventilation. CIP: Reduction in or absence of deep tendon reflexes and sensory loss.