This module will provide you with key strategies for meeting both professional and hospital documentation requirements because hospital reimbursement and quality metrics are dependent upon physician documentation

• Chief Complaint
– Be clear about which complaint (if there are multiple) is the reason for inpatient hospitalization
• Chronic conditions don’t usually require hospitalization unless the condition is exacerbated
– Document the risk associated with not treating the chief complaint in the inpatient hospital setting
• Concern for specific complications/adverse outcome
• The likelihood of an adverse outcome if not treated in the inpatient setting

• History of Present Illness
– Includes all the clinically relevant elements related to the chief complaint (why the patient is seeking/ requires inpatient medical care) and includes the information on the following slides:

• Duration
– How long has the patient had the chief complaint?
• Be as specific as possible e.g., onset within last 24 hours, onset within last week, exacerbated chronic condition, etc.
• Severity
– Is this a “typical” or “chronic” presentation or is the chief complaint a new concern?
• Be sure to note how the patient's condition differs from baseline if this an exacerbation of a chronic condition
• Be sure to highlight any “acute” or new sysmptoms

• Associated Signs & Symptoms
– Explain the probability of an adverse outcome without immediate treatment or intervention
– Differentiate new conditions from chronic illnesses; note when outpatient treatment failed and when the condition poses a threat to life or bodily function
• Clearly specify which are new complaints requiring workup and include the term “acute”
• Document your suspected etiology stating “evidence of
. . .” requiring further workup

• Always note an abrupt change in neurological status
• For existing conditions that are not chronic, state if the condition is resolved or if treatment continues
– “Treated at outside hospital (OSH) for pneumonia; will continue to monitor and treat”
– “Treated at OSH for pneumonia; appears resolved”

Chronic conditions
– Include all relevant co-morbidities/ diagnosis that contribute to the complexity or severity of the case clearly noting
• A severe exacerbation of a chronic condition
• Progression of a chronic condition
• Side effects of treatment for a chronic condition

• Some chronic conditions have associated diagnoses that require more detail:
– Consider “chronic respiratory failure” if on home oxygen, CPAP or BIPAP with COPD or obstructive sleep apnea
– Consider “obesity hypoventilation syndrome” for the morbidly obese
– List all behavioral disturbances for a patient with dementia, noting the type if known
– Specify the type of heart failure as systolic (more common) or diastolic, or both

• Always note when the patient has failed to follow his/her treatment plan, e.g., missed follow up appointments, non-compliance with medications, etc.
– The valve of this information will increase with the
CMS Quality Measure of readmissions as it is important to demonstrate when a readmission was unavoidable due to a lack of patient compliance with the treatment plan

• If you suspect morbid obesity or malnourishment always note it and document how this condition complicates or exacerbates treatment
– You may want to order nutritional consult which will provide a BMI to support the diagnosis; however, you must document the BMI
• Include the observations of cachexia/cachetic or emaciated when applicable for general appearance

• Address the immunization status of pneumonia and flu vaccines
– Start asking the status of flu vaccination in
September as Quality Measures are based on discharge dates so a patient can be admitted prior to flu season but discharged during flu season
• If excessive alcohol use requires treatment with vitamins/banana bag, consider documenting
“evidence of thiamine deficiency”

• Consider the diagnosis of “narcotic dependence”
(which isn’t the same as abuse) for any patient who has long term use of narcotics or other prescribed substances that lead to a physiological response if abruptly discontinued
– Note any withdrawal symptoms
– Specify the type of narcotic
– This diagnosis should always be considered on any patient requiring evaluation by the pain management team

• Documentation of medical decision making should occur daily, so each note should contain
– Current condition of the patient
• “Remains unstable,” “remains exacerbated,” progression of symptoms, “stable with continued concern for . . .”
• Daily documentation must support the continued need for hospitalization
– Adults who are stable for ≥ 12 hours should be transitioning to the next level of care

• State all diagnoses being evaluated or treated each day
– Consider use of a problem list allowing for daily documentation of the status of the condition
– Note when a suspected diagnosis has been ruled
out AND when a diagnosis/complaint has been resolved
– Link the chief complaint and its etiology to the symptoms that were present on admission (POA) especially when the etiology is not identified until several days within the admission e.g., sepsis, pneumonia

• Always document the onset of new conditions that occur during hospitalization as “acute”
– Be sure to provide documentation and an associated diagnosis for any phone orders
• Note when you have reviewed and/or discussed diagnostic tests with the performing or interpreting physician
– “Reviewed radiologist findings and agree”

• Reiterate the chief complaint and resultant etiology or suspected etiology (“evidence of”) and note when symptoms of this condition were present on admission
– Patient presented with XYZ secondary to underlying admitting diagnosis of XYZ
– Patient admitted due to XYZ as evidenced by XYZ presenting symptoms

• List all the diagnoses that were evaluated stating which diagnoses were ruled out and which were treated
• Differentiate new conditions that required workup from chronic conditions that were exacerbated or progressed during the admission
• Be sure to know when the patient required
“monitoring” for a condition e.g., cerebral edema, as it may appear that treatment was not rendered

• Include any “suspected,” “likely,” “probable,” or “possible” diagnosis that will require additional care following discharge
• Always note when the patient requests discharge prematurely
• Always note the patient’s condition upon discharge, verifying the patient was “medically stable” or “palliative care,” etc.

• The CDI staff is composed of nurses (and coders) that will help you translate the complexity of your patients into diagnoses that can be captured by ICD-9 codes (Call 555-
5555)
• Both quality measures and reimbursement are dependent upon ICD-9 code selection

• Whenever there is clinical evidence suggestive of a more definitive principal diagnosis and/or the presences of an incomplete or missing diagnosis , the CDI nurse will “query” the physician for guidance in interpreting the clinical evidence.
• You can always disagree or state the condition
isn’t clinically significant or is an incidental finding
• Coders can’t infer or assume, so sometimes CDI staff must ask for documentation that seems obvious and/or ask you to “link” a symptom to a diagnosis

• Include information about your organization’s query process
– Verbal, paper, electronic?
– Can the medical staff document on the query form?
• Part of the medical record or not?
– How does the medical staff respond to a query?
• Is there a timeframe in which they can respond?
– What does the provider do if he/she has a question?
– Is there a query escalation process?

The response time goal for queries is < 24 hours
A response should be made to every query whether you agree or disagree
– If you agree , please update the chart to address the queried issue even if the issue has been resolved
• Add to the next progress note
– Example  “Resolved acute respiratory failure”
• Add to discharge summary
– Example  “Experienced acute respiratory failure; resolved with . . . (tx)”