Clinical Documentation

Posted on Dec 27, 2012 in Clinical Documentation | 0 comments

Proper physician documentation in the medical record is essential for many reasons. Such accurate documentation of inpatient diagnoses, to include co-morbid conditions, allows the coders to bill third party payers properly for the necessary services that our hospital is providing. Correct documentation will permit the more accurate assessment of mortality risk, thereby improving the accuracy of our hospital’s observed vs. expected mortality ratio (O/E ratio). Finally, morbidity and mortality data are being accumulated by Medicare on each physician. It is in each physician’s best interest to accurately include all clinical information in the documented medical record.

Congestive heart failure (CHF) is our most common inpatient DRG; however, it is important that physicians document more in the medical record than just CHF. Ideally, the documentation would include whether the CHF is due to systolic or diastolic dysfunction. It should be noted whether the CHF is acute, chronic or acute-on-chronic. Finally, the New York Heart Association (NYHA) heart failure class should be included in the medical record. A thorough discharge summary, which includes these CHF characteristics as well as all co-morbid conditions, is probably the most efficient method for such documentation. 

By Dean J. Nickles, M.D.
Medical Director, Utilization Management

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