CLINICAL DOCUMENTATION PEARLS
FOR PHYSICIANS, PAs AND NPs
SEPTEMBER 2014
Wording of Documentation: "History of" Is Not the Same As "Recurrent"
Specific language that accurately reflects a patient's clinical condition is essential in medical
record documentation. Use of the terms "recurrent" and "history of" illustrates this point.
"History of" should be used to describe a past condition which no longer exists and currently
requires no treatment. Use “recurrent” to describe a past condition which once again actively
exists and requires monitoring, evaluation and/or treatment during the current hospitalization.
For example, if a diabetic patient is admitted with vomiting secondary to gastroparesis, the
record should state "diabetic patient with recurrent diabetic gastroparesis." The true complexity
of the care provided for this patient would be reflected in a final coded diagnosis of diabetic
gastroparesis. In the event that the patient's vomiting was due to a condition other than
gastroparesis (e.g. pancreatitis, small bowel obstruction, cholecystitis etc…) then the term
"history of" should be used. The record should then read "diabetic patient with a history of
diabetic gastroparesis presents with vomiting secondary to small bowel obstruction." The coding
would then reflect the historical diabetic complication and the current bowel obstruction.
Some other commonly seen recurrent but active conditions that are often documented only as
"history of", thereby failing to accurately portray the patient's current condition, include:
Congestive heart failure
Respiratory failure
Peripheral neuropathy
Seizure disorders
Urinary tract infections
Pancreatitis
Skin abnormalities—e.g. pressure ulcers
Renal failure
ICD 10: Greater Specificity Achieved by Linking a Condition to the Underlying Disease
Documentation of any underlying or associated conditions permits greater specificity in code
selection and supports the care provided and resources used. Many diseases have common
complications and manifestations that should be documented in conjunction with the main
disease process. For example:
Diabetes causes numerous complications such as neuropathy, nephropathy, gastroparesis and
skin ulcers, all of which need to be directly linked to their root cause (i.e. the diabetes) in the
record. Documenting "patient with diabetes, chronic renal failure, blindness, and vomiting"
neither accurately describes the patient's condition nor achieves the same coding specificity as
"patient with diabetes type II with the following diabetic complications: nephropathy resulting
in CKD stage III, retinopathy resulting in blindness, and gastroparesis causing vomiting."
For any questions or comments, please contact the Clinical Documentation
Improvement Team at 301-754-8641.
1