Documentation Tip Card: General Documentation Tips

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Excellent documentation supports excellent care .Department of Veterans Affairs,Aleda E. Lutz VAMC Clinical Documentation Improvement ProgramDepartment of Veterans Affairs,Aleda E. Lutz VAMC Clinical Documentation Improvement ProgramDoc um en ta t io n T i p C a r d:G e ner a l D oc um en t at i o n T i psDoc um en ta t io n T i p C a rd:G e ner a l D oc um en t at i o n T i psClinical Documentation is important for a variety of reasons. These include:Coding accuracy and precision,Documentation of the severity of illness,Justification for resources used in providing care,Improved continuity of care for the Veteran, andReimbursement both from the VA and commercial payers.Lack of accurate and complete documentation may not allow a Veteran to get benefits they deserveand also reflects on you as providers in other VA Medical Centers and Clinics read your noteswhen the Veteran either moves or seeks care at another facility. If your documentation allows thenext provider seeing the Veteran to have a better starting point, especially for recurrence of common symptoms, that only helps the Veterans in getting timely care to help resolve those conditionsand provides better utilization of resources to identify the underlying cause. Documentation that isnot clear may result in a clarification request to allow for precise coding of the record and documentation of the care provided.If you have any questions or concerns regarding documentation in the medical record, do not hesitate to contact the facility Clinical Documentation Improvement Specialist at the phone or emailbelow. After all, we are here to serves those who have served.Robert S Hodges, MSN, RN:ATTN: PAS/136; 1500 Weiss Street; Saginaw MI, 48602Phone: 989-497-2500 x13101E-mail: Robert.Hodges2@va.govExcellent documentation supports excellent care.Make sure you document all conditions that are impacting the patients health at the time oftheir visit and review any chronic conditions. For example;Acute aspiration pneumonia with chronic diastolic heart failure.Acute kidney injury secondary to Sepsis or Dehydration.Morbid Obesity (BMI 39) or Malnutrition (BMI 19)If a patient presents with symptoms, such as dyspnea, chest pain, or edema, indicate the causeor what you are ruling out. For example;Dyspnea due to COPD vs. Asthma vs. Pneumonia,Chest pain due to GERD vs. Angina vs. Costochondritis, orEdema due to Diastolic CHF vs. Chronic Kidney Disease vs. something else.When documenting conditions be as precise as possible. This allows for more accurate coding and better documentation of the patients condition. For example:Systolic and/or Diastolic CHF and is it acute or chronic.Diabetes Type 1 or Type 2 and controlled or uncontrolled.Robert S Hodges, MSN, RN:ATTN: PAS/136; 1500 Weiss Street; Saginaw MI, 48602Phone: 989-497-2500 x131011E-mail: Robert.Hodges2@va.gov2Excellent documentation supports excellent care .Excellent documentation supports excellent care.Department of Veterans Affairs,Aleda E. Lutz VAMC Clinical Documentation Improvement ProgramDepartment of Veterans Affairs,Aleda E. Lutz VAMC Clinical Documentation Improvement ProgramDoc um en ta t io n T i p C a r d:G e ner a l D oc um en t at i o n T i psDoc um en ta t io n T i p C a rd:G e ner a l D oc um en t at i o n T i psWhen providing patient education not only document the information provided, but also thepatients response to the education you provided. This is a Joint Commission standard.Make the link between conditions. If a patient has Diabetes Mellitus, do they have neuropathies, renal manifestations, or other issues related to that primary condition. If they have anencephalopathy, what is the underlying condition causing the encephalopathy? Links cannotbe assumed or presumed and must be documented by the provider and better documents theclinical condition of the patient.Be very cautious with the use of abbreviations. The facility approved list is available underthe tools menu in CPRS, but it is over 800 pages long and many abbreviations on that listhave more than one meaning and mean different things in upper and lower case. Improperuse of abbreviations can cause confusion and may require clarification. As a general rule:Never use a slash (/) between diagnoses.Abbreviations should never be used in the final diagnosis listingIf you aren’t sure, write it out.Robert S Hodges, MSN, RN:ATTN: PAS/136; 1500 Weiss Street; Saginaw MI, 48602Phone: 989-497-2500 x13101E-mail: Robert.Hodges2@va.gov3Acute vs. Chronic. It’s important to document conditions as Acute or Chronic, or even anAcute Exacerbation of a Chronic condition, such as CHF, COPD or Chronic Kidney Disease.This helps capture the severity of illness as well as precision in coding.Insufficiency vs. Failure. These two terms are often used synonymously in medical practice, but they do not mean the same thing and indicate different levels of severity.Insufficiency more accurately describes an new change or an acute change in achronic condition that can be treated as an outpatient or observation status and isexpected to return to baseline with minimal intervention that cannot be staged orclassified using established criteria.Failure usually indicates something more serious or dramatic in nature which , ifacute in nature, may require inpatient or critical care services and may have impact on other body systems. If chronic in nature, the condition will require continued care an monitoring and is not expected to improve in the long term. Theseconditions should be able to be staged or classified using existing standards.Robert S Hodges, MSN, RN:ATTN: PAS/136; 1500 Weiss Street; Saginaw MI, 48602Phone: 989-497-2500 x13101E-mail: Robert.Hodges2@va.gov4

Excellent documentation supports excellent care .Excellent documentation supports excellent care.Department of Veterans Affairs,Aleda E. Lutz VAMC Clinical Documentation Improvement ProgramDepartment of Veterans Affairs,Aleda E. Lutz VAMC Clinical Documentation Improvement ProgramDoc um en ta t io n T i p C a r d:E v al u at i o n & M a na g e m ent ( E /M) : L e ve l 1 ( 1 99 5)Doc um en ta t io n T i p C a rd:E v al u at i o n & M a na g e m ent ( E /M) : L e ve l 2 ( 1 99 5)Minimum requirements for a level 1 exam are:Minimum requirements for a level 2 exam are:S - Chief Complaint: history of present; 1 of the 8 elements must be documented: location, dura-S - Chief Complaint: history of present illness (1 of the 8 elements: location, duration, timing,tion, timing, severity, quality, context, modify factors, associated symptoms (New patient).O - Minimum of 1 body system/area (i.e. GI: GU: CV: Skin: Musculoskeletal, etc)severity, quality, context, modifying factors, associated signs/symptoms), One review of systemtaken from patient (New Patient)O - Minimum of 2 body systems in detail (i.e. GI: GU: CV: Skin: Musculoskeletal (NewA - One minor problem identified (i.e. cold, insect bites, influenza, etc.*) or being seen for previously diagnosed problem that is stable or improving.P - Minimal treatment required (i.e. injection, bed rest, and chest x-ray/lab tests)*Many Veterans have multiple chronic conditions which may increase the level of care.**Code 99211 is the only E/M code available for use by non-providers. Providers would rarelyassign a level of 99211.Patient) or minimum of 1 body systems/area examined (Established Patient)A - One minor problem identified (i.e. cold, insect bites, influenza, etc.) or being seen for previously diagnosed problem that is stable or improving.P - Minimal treatment required (i.e. injection, bed rest, and chest x-ray/lab tests)(source Physician Documentation Tips and Guidelines 2011; ce Physician Documentation Tips and Guidelines 2011; t S. Hodges, MSN, RN:ATTN: PAS/136; 1500 Weiss Street; Saginaw MI, 48602Robert S. Hodges, MSN, RN:E-mail: Robert.Hodges2@va.govPhone: 989-497-2500 x13101Phone: 989-497-2500 x13101ATTN: PAS/136; 1500 Weiss Street; Saginaw MI, 48602E-mail: Robert.Hodges2@va.gov56Excellent documentation supports excellent care .Excellent documentation supports excellent care.Department of Veterans Affairs,Aleda E. Lutz VAMC Clinical Documentation Improvement ProgramDepartment of Veterans Affairs,Aleda E. Lutz VAMC Clinical Documentation Improvement ProgramDoc um en ta t io n T i p C a r d:E v al u at i o n & M a na g e m ent ( E /M) : L e ve l 3 ( 1 99 5)Doc um en ta t io n T i p C a rd:E v al u at i o n & M a na g e m ent ( E /M) : L e ve l 4 ( 1 99 5)Minimum requirements for a level 3 exam are:Minimum requirements for a level 4 exam are:S - Chief Complaint: history of present illness must include 4 of 8 elements at a minimum or 3S - Chief Complaint: history of present illness (must include 4 of 8 elements at a minimum or 3chronic conditions for New patient and 1 at a minimum for an Established patient.chronic conditions.Review of systems (verbal) (i.e. any problems such as weight loss, dizziness, etc.)Review of systems (verbal) (10 systems reviewed with patient)Past medical history (patients)Past medical historyFamily HistorySocial or Family History (all 3 PFSH for New Patient, 1 PFSH for EstablishedPatient)Social History (patient’s past medical history at a minimum)O - Minimum of 2 body systems in detail (i.e. GI: GU: CV: Skin: Musculoskeletal (NewO - At least eight body systems/areas systems (New Patient) or at least 2 body sys-Patient) or minimum of 2 body systems/areas (Established Patient)tems/areas (Established Patient)A - New problem to the provider - additional workup planned; one or more chronic problems withmild exacerbation; two or more stable chronic illnesses; acute complicated injury. Normally threeor more diagnoses are documented.P - Order/review tests; prescription drug therapy; elective minor surgery; invasive diagnostic tests(i.e. scopes)A - Conditions found - self-limiting or minor conditions (at a minimum) such as a chronic condition - patient stable, and/or new problem to the provider with no additional work-up planned.P - Treatment recommendation usually a prescription drug, minor surgery with no identified riskfactors, physical therapy, IV fluids without additives.(source Physician Documentation Tips and Guidelines 2011; ce Physician Documentation Tips and Guidelines 2011; t S. Hodges, MSN, RN:ATTN: PAS/136; 1500 Weiss Street; Saginaw MI, 48602Robert S. Hodges, MSN, RN:Phone: 989-497-2500 x13101E-mail: Robert.Hodges2@va.govPhone: 989-497-2500 x131017ATTN: PAS/136; 1500 Weiss Street; Saginaw MI, 48602E-mail: Robert.Hodges2@va.gov8

Excellent documentation supports excellent care .Excellent documentation supports excellent care.Department of Veterans Affairs,Aleda E. Lutz VAMC Clinical Documentation Improvement ProgramDepartment of Veterans Affairs,Aleda E. Lutz VAMC Clinical Documentation Improvement ProgramDoc um en ta t io n T i p C a r d:E v al u at i o n & M a na g e m ent ( E /M) : L e ve l 5 ( 1 99 5)Doc um en ta t io n T i p C a rd:Doc um en ti n g A bd om in a l P ai nMinimum requirements for a level 5 exam are:S - Chief Complaint: history of present illness (must include 4 of 8 elements at a minimum or 3chronic conditions.Review of systems (verbal) (10 or more systems reviewed with patient)Past medical historyDocumenting the underlying cause of a sign or symptoms as precisely as possible assistsin continuity of care, documenting severity of illness, and coding precision. AbdominalPain is a symptom that normally represents an underlying condition. Some of the common underlying cause of abdominal pain include, but are not limited to:Renal stitisIleus or ObstructionFood PoisoningGastric UlcersUrinary Tract InfectionAAA LeakSocial HistoryFamily History (all 3 PFSH for New Patient, 2-3 PFSH Established Patient)O - At least eight body systems/areas for both New and Established PatientsA - New problem to the provider with additional work-up planned; two or more chronic illnesseswith severe exacerbation; acute injuries, illnesses that pose a threat to life or bodily function;abrupt change in neurologic status (i.e. seizure, TIA, sensory loss, etc.)P - Emergency or elective major surgery: drug therapy requiring intensive monitoring for toxicityThis list goes on, but if you know or suspect a cause it’s important to document that. Ifyou don’t know the cause, indicate what you are working up or ruling out.(source Physician Documentation Tips and Guidelines 2011; t S. Hodges, MSN, RN:ATTN: PAS/136; 1500 Weiss Street; Saginaw MI, 48602Robert S. Hodges, MSN, RN:E-mail: Robert.Hodges2@va.govPhone: 989-497-2500 x13101Phone: 989-497-2500 x13101ATTN: PAS/136; 1500 Weiss Street; Saginaw MI, 48602E-mail: Robert.Hodges2@va.gov910Excellent documentation supports excellent care .Excellent documentation supports excellent care.Department of Veterans Affairs,Aleda E. Lutz VAMC Clinical Documentation Improvement ProgramDepartment of Veterans Affairs,Aleda E. Lutz VAMC Clinical Documentation Improvement ProgramDoc um en ta t io n T i p C a r d:Doc um en ti n g Ac i dos is & A lk a los isDoc um en ta t io n T i p C a rd:Doc um en ti n g Ac ut e K i dn e y I nj ur yDocumenting as precisely as possible assists in continuity of care, documenting severityof illness, and coding precision:Documenting as precisely as possible assists in continuity of care, documenting severityof illness, and coding precision:Acidosis and Alkalosis are important complications to capture in a patients presentation. When documenting these conditions it is important to document:If it is Respiratory and/or Metabolic, and;If it is compensated or uncompensated, and;The underlying cause or suspected s: pH 7.35pH 7.35-7.45Alkalosis: pH 7.45Alkalosis: CO2 35RespiratoryCO2 35-45Acidosis: CO2 45Acidosis: HCO3 22MetabolicHCO3 22-26Alkalosis: HCO3 26Acute tubular necrosisAcute Renal Insuffi-Acute kidney injuryUnknown causeAcute Kidney Injury Network (AKIN) staging system for Acute Kidney InjuryAKIN StageSerum Creatinine criteriaUrine Output Criteria1SCreat 26.4 mmol/L or SCreat 150—200% (1.5-2fold) from baseline 0.5ml/hg/h for 6h2SCreat 200—300% ( 2-3 fold) from baseline 0.5 ml/kg/h for 12h3SCreat 300% ( 3 fold) from baseline or SCreat 354 mmol/L with an acute rise of 44 mmol/L in 24hor initiated on Renal Replacement Therapy(irrespective of stage at time of initiation). 0.3 ml/kg/h for 24 horanuria for 12 h.Robert S. Hodges, MSN, RN:ATTN: PAS/136; 1500 Weiss Street; Saginaw MI, 48602Robert S. Hodges, MSN, RN:Phone: 989-497-2500 x13101E-mail: Robert.Hodges2@va.govPhone: 989-497-2500 x1310111Acute Renal FailureOther causeATTN: PAS/136; 1500 Weiss Street; Saginaw MI, 48602E-mail: Robert.Hodges2@va.gov12

Excellent documentation supports excellent care .Excellent documentation supports excellent care.Department of Veterans Affairs,Aleda E. Lutz VAMC Clinical Documentation Improvement ProgramDepartment of Veterans Affairs,Aleda E. Lutz VAMC Clinical Documentation Improvement ProgramDoc um en ta t io n T i p C a r d:Doc um en ti n g Ac ut e R en a l Fa i l ur eDoc um en ta t io n T i p C a rd:Doc um en ti n g A lt er e d Me n ta l St at usDocumenting as precisely as possible assists in continuity of care, documenting severityof illness, and coding precision:Documenting an alteration in mental status is vague and may not accurately representthe underlying condition or suspected cause. For the continuity of care of our Veteransit is important to be as precise as possible. The three things to consider when documenting an alteration in mental status are:Acute tubular necrosisAcute Renal InsufficiencyAcute Renal FailureOther causeAcute kidney injuryUnknown causeRIFLE CriteriaStageGlomerular Filtration RateUrine Output CriteriaSerum Creatinine (SCr) increased 1.5 times or GFRdecreased 25% 0.5ml/kg/h for 6 hoursInjurySCr increased 2.0 times or GFR decrease 50% 0.5ml/h for 12 hoursFailureSCr increased 3.0 times or GFR decreased 75% or SCr 4 mg/dL; acute rise 0.5 mg/dL 0.3 ml/kg/h for 24 h oranuria for 12 hoursLossPersistent Acute Renal Failure; complete loss of kidney function 4 weeksEnd StageEnd Stage Renal Disease (ESRD) persisting 3 monthsRiskRobert S. Hodges, MSN, RN:ChronicityAcute, Chronic, Acute on Chronic, Other, or Unable to determineNature:Dementia, Delirium, Psychosis, Obtundation, Other, or Unable to Determine.Underlying Cause:Alzheimer’s Disease, Encephalopathy (indicate the type and underlyingcause), Lewy body dementia, Acute stroke, Late effect of stroke, TransientIschemic Attack (TIA), Generalized cerebral edema, Seizure disorder(indicate its nature and whether status epilepticus is present or if symptomsare intractable), Normal pressure hydrocephalus, Psychiatric Illness(specify type if possible), Other, or Unable to DetermineIf you don’t know the cause, indicate what you are working up or ruling out.ATTN: PAS/136; 1500 Weiss Street; Saginaw MI, 48602Robert S. Hodges, MSN, RN:E-mail: Robert.Hodges2@va.govPhone: 989-497-2500 x13101Phone: 989-497-2500 x1310113ATTN: PAS/136; 1500 Weiss Street; Saginaw MI, 48602E-mail: Robert.Hodges2@va.gov14Excellent documentation supports excellent care .Depart ment o f Veterans Affa irs,A le da E. Lut z V AM C C lin ic a l Do cu me nt at io n I mp ro ve me nt Pro gra mDepartment of Veterans Affairs,Aleda E. Lutz VAMC Clinical Documentation Improvement ProgramDoc um en ta t io n T i p C a r d:Doc um en ti n g A nem i aDoc um en ta t io n T i p C a rd:Doc um en ti n g Ch es t P a inDocumenting as precisely as possible assists in continuity of care, documenting severityof illness, and coding precision:Documenting as precisely as possible assists in continuity of care, documenting severityof illness, and coding precision:Acute Blood Loss AnemiaExpected Acute Blood Loss AnemiaAnemia of Chronic DiseaseIron Deficiency AnemiaAplastic AnemiaPernicious AnemiaChronic Blood Loss AnemiaAnemia of unknown etiologyPrecipitous drop in HemoglobinAnemia secondary to antineoplastic or otherdrug therapyNote: Postoperative Blood Loss Anemia is not coded as a complication; unless specified as a complication by the physician (per Coding Clinic)(20% from baseline not related to anemia)If you are not sure of the cause of the anemia, please document what you suspect and areruling in or out.Excellent documentation supports excellent care.Chest pain is a symptom that normally represents an underlying condition. It is important to identify the underlying cause of any symptom to the best of your ability. Possible diagnoses include but are not limited to the following, but don’t forget there may beother causes or an unknown cause that you only suspect, and it is important to document your suspicions as well.Acute Myocardial tisGastroesophageal Reflux DiseaseEsophagitisOther or Unknown causes(but don’t forget your suspicions or what you are working up or ruling out)Robert S. Hodges, MSN, RN:ATTN: PAS/136; 1500 Weiss Street; Saginaw MI, 48602Robert S. Hodges, MSN, RN:Phone: 989-497-2500 x13101E-mail: Robert.Hodges2@va.govPhone: 989-497-2500 x1310115Coronary Artery DiseaseCholecystitisCostochondritisATTN: PAS/136; 1500 Weiss Street; Saginaw MI, 48602E-mail: Robert.Hodges2@va.gov16

Excellent documentation supports excellent care .Department of Veterans Affairs,Aleda E. Lutz VAMC Clinical Documentation Improvement ProgramDoc um en ta t io n T i p C a r d:Doc um en ti n g Co n ges t i v e He ar t F a i lu reDocumenting as precisely as possible assists in continuity of care, documenting severityof illness, and coding precision:Excellent documentation supports excellent care.Department of Veterans Affairs,Aleda

Excellent documentation supports excellent care. 4 Documentation Tip Card: General Documentation Tips Dep ar tm e n t o f V et e r a n s Af f a i rs , Al ed a E . L u tz V AMC Cl i n ic a l Do c um e nt a t io n Imp ro v em e n t P r o g ra m Acute vs. Chronic. It’s important to document conditions as Acute or Chronic, or even an

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