Clinical Documentation

Transfusion Risks

Posted on Jan 3, 2017 in Clinical Documentation | 0 comments

Please click on link for the Epic Transfusion Risks:

From Annette Shaieb, M.D.
Medical Director, Clinical Laboratory

Understanding Clinical Documentation Integrity/Improvement

Posted on May 5, 2016 in Clinical Documentation | 0 comments

The transition to ICD-10 necessitates that physicians document more precisely, completely and consistently than before.

Clinical Documentation Integrity/Improvement (CDI) is the link between physicians and the coding department. Coders translate physician documentation into ICD-10 codes.

These codes are the basis of MS-DRG assignment, severity of illness, other risk rankings and observed:expected mortality scores.

Because coding terms are often not the same as commonly used clinical language, it’s not always obvious how to best document a condition. When clarity is needed, a query is a way to obtain this information.

There are two types of queries—CDI and coding. The former usually occurs during the hospitalization, the latter occurs after discharge. Queries aren’t trying to question your diagnosis, they are to help optimize your documentation.

Try to answer the CDI query promptly. Any clarified diagnoses should then be documented in the progress note and discharge summary.

If you don’t understand the query, contact the CDI team, especially before selecting the “unable to determine” option.

At Summit, call Ext. 7945 or 7946 to reach Sandra Christensen-Waldear, R.N., or Jane Banks, R.N., and 510-612-7085 to reach Beth Gong, M.D.

Please document diagnoses rather than just symptoms and lab findings (e.g. “pneumonia” rather than

“infiltrate and cough” and “lactic acidosis” rather than “elevated lactate”)

ICD-10 is about specifics such as acuity, type and etiology. For example, “acute diastolic heart failure due to rapid atrial fibrillation” is more specific than “CHF and atrial fibrillation”)

Clearly state conditions present on admission (POA) —especially catheter-related infections and pressure ulcers. Physicians should document the location of the ulcers but can leave the staging to the wound R.N.

It is important to be clear when there is an association or linkage between conditions. For example, it is clearer to the coder if you document “gastroparesis due to type 2 diabetes” rather than “gastroparesis in the setting of diabetes” or “diabetes and gastroparesis.”

When there is diagnostic uncertainty, inpatient coding allows for use of modifiers such as “suspected,” “possible” and “probable.” If a diagnosis remains “likely” or “suspected” at the time of discharge, be sure to document this in the discharge summary. Similarly, be sure to document when such diagnoses are “ruled out.”

Just because we can copy and paste, doesn’t mean we should. Without careful editing, inaccurate and outdated information keeps moving forward with copy and paste.

Specific words matter—physician documentation should be complete and precise for both the principal diagnosis as well as all the secondary diagnoses and co-morbidities—this is how you show how sick your patient really is.

By Beth Gong, M.D.
CDI Physician Champion, Alta Bates Summit

Physicians and ICD-10

Posted on Oct 1, 2015 in Clinical Documentation | 0 comments

ICD-10 Key Facts:

  • The federally-mandated ICD-10 compliance date is 10/1/15.
  • ICD-10 requires additional diagnosis specificity in three axes: (mnemonic SEAL the deal)
  • Severity of illness (e.g. Stage 2 cancer), Etiology, Anatomy (body site) including Laterality
  • About 25 percent of new codes are based on laterality (left, right, bilateral), and 25 percent are related to encounter type (first, second, sequela) or pregnancy trimester (1st, 2nd, 3rd).
  • The Sutter E H R ICD-10 Diagnosis Calculator and Problem List Calculator prompt physicians to document with the level of specificity required for ICD-10. The current diagnosis look-up tool will  remain the same with physicians entering diagnosis terms (e.g. pneumonia) rather than codes

It’s not too late

  •  Practice using ICD-10 Diagnosis terms (not codes) as well as adding specificity for procedures performed at the hospitals
  •  Review your office written order forms to ensure they are ICD-10 compliant.
  •   ICD-10 General Trainings in HealthStream: ( are named:
    • The Language of ICD-10: Specificity and Granularity
    •  Documenting in ICD-10-CM
    • Documenting in ICD-10-PCS
  • ICD-10 Specialty Training in HealthStream:
    • Take at least one (1) additional specialty-specific course (e.g. “ICD-10 and Pediatrics” for pediatricians or “ICD-10 and Dermatology” for dermatologists)
  • Work with your Coders and Clinical Documentation Specialist to check your compliance with ICD-10.  Respond to queries timely

Note: Additional training materials, including ICD-10 WebEx sessions and training videos, are available on the ICD-10 portal for viewing at http://mysutter/Resources/ICD10.

By Alisa Stinn, RHIT
Client Location Lead, Health Information Management


Cancer Staging in the Sutter EHR

Posted on Jun 3, 2014 in Clinical Documentation | 0 comments

With the implementation of Cancer Staging functionality in the Sutter EHR, there is now a standard location and method for documenting this important clinical information in the medical record. Users can now access electronic versions of the American Joint Commission on Cancer (AJCC) staging forms directly within the Problem List entry for the patient’s cancer.

It is essential that each cancer diagnosis receive staging. Please note that in order to meet our accreditation standards, staging is to take place within 30 days of the diagnosis. Read More

New Regulations From CMS

Posted on Jan 7, 2014 in Clinical Documentation | 0 comments

The Center for Medicare and Medicaid Services (CMS) has come out with new regulations for determining inpatient and outpatient status for services provided in the hospital. In order to qualify as an inpatient, there must be a two midnight benchmark. Every decision to admit a patient to inpatient status should be based on the physician’s expectation that the hospital stay would span two midnights. Furthermore, that two midnight stay must be documented to be medically necessary. If a physician cannot reasonably expect the patient to spend two midnights in the hospital, then that patient should be admitted to observation status. If that patient then spends two midnights in the hospital, the status can be changed from observation to inpatient during that admission as long as medical necessity is documented in the medical record. Read More

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. Read More