Clinical Documentation
Improvement
Newsletter
Vol 1, Issue No. 3, July 2012
Diagnoses that
Impact/Change
Severity
Documentation Superstar:
Dr. Joanna Kokoszka
“Her documentation is exceptional and
she is a great role model for all.” CDI Team
Physicians, we depend on
you for Diagnosis
Documentation, NOT signs and
symptoms.
Signs and Symptoms followed by
diagnosis vs diagnosis will be coded to
the symptom. This may not reflect
accurate severity of illness. To code
the diagnoses, document diagnosis vs
diagnosis without the symptom in
front of it!
Preferred: CVA vs TIA in the DC
summary, will code to CVA
Not preferred: AMS – CVA vs TIA
in the DC summary codes to AMS.
-Functional Quadriplegia- The
inability to move d/t another
condition (e.g., dementia, severe
contractures, arthritis, spasticity,
etc.). The patient is immobile from
a severe physical disability or
frailty.
-Cerebral edema/effusion,
cerebral compression
-Encephalopathy: diffuse disease
of brain that alters function or
structure with many causes:
advanced disease states, infection
hypoxia, brain tumor, ICP, trauma,
poor nutrition and decrease blood
flow. The hallmark of
encephalopathy is AMS
(Harrison’s).
-Delirium as a manifestation of
Locked-in-state
Coma
Neurological neglect
Attached notes are not considered a
part of the record for coding purposes
unless a physician references them by
date and author of the note.
CVA vs TIA




Specify area of brain
Specify vessels involved
Specify cause
If occlusion or stenosis is
present, also identify if an
infarction is present?
 Clarify when diagnoses are
ruled out
Who will be next month’s
Superstar????
encephalopathy
-Late effects of CVA
Paresis/Plegia-specify if
dominant or nondominant side,
hemi/quad/para? --L or R is not
sufficient
HA/headache
Seizures
Dysphasia-speech deficit
Dysphagia-swallow deficit
Cognitive deficits
Resource Help
Laurie Banker, RN Ext 36124
Tracy Boldt, RN Ext 30818
Angie Boylan, RN Ext 35168
Melson Elemino, RN Ext 30819
Diann Hinke, RN Ext 36651
Kim MaGee, RN Ext 35424
Dr. Melissa Buchner-Mehling
Clinical Documentation website: http://facets.parknicollet.com/cdmp/