Practice Clinical Doccumentation

Practice Clinical Doccumentation

Medical Records Clinical Documentation Program   

The Clinical Documentation Program continues its ongoing effort to improve the quality of the medical record and ensure accurate DRG assignment. Coders may need clarification before they can finalize the record. We then query the physician for additional documentation. Often queries are asked concurrently, before the pt is discharged. This is a preferred time to obtain the necessary information needed to finalize the record. A question is written on a bright green CDMP worksheet and placed on top of the progress notes with a red sticker that states missing information. If you agree with the question, please document what is needed in the progress notes. If you do not agree please check the "I disagree because" box and state your reasoning. Please answer the query at that time to avoid a later communication with the CDMP staff. We want to improve our timeliness for billing the medical record within the 48 hours of coding.

 

Coders need to know if you agree with your consultants' diagnosis. Please acknowledge their diagnoses in the body of the medical record. Listing all diagnosis in the discharge summary is helpful. It is the attendings responsibility to state patients final diagnosis. Remember, coders can't code from X-rays, lab values or path reports. They can only code these if documented by the physician. The terms HTN urgency or HTN crisis are not recognized. Physicians must use the terms accelerated or malignant instead. Fluid overload, chest pain, pulmonary edema and acute respiratory distress syndrome are sign and symptoms. We need the suspected etiology documented.

 

With the assistance of our physicians, physician liaisons and support of administration, we can reach our goal of capturing accurate DRG assignment.

 

By Brenda Pulliam

 

 



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