• In general, medical coding can be drawn from documentation from any healthcare provider (consultants, residents, nurse practitioners, physician assistants, etc.).
• If there is a documentation conflict between two physicians, a Clinical Documentation Improvement specialist will look for clarification from the patient's admitting physician, as that person is responsible for the final diagnosis.

• Consider the following dimensions when documenting a patient's conditions:

  • Where (site and laterality)
  • Specificity (the most detailed diagnosis to match the patient’s condition)
  • Timing (acute or chronic)
  • Manifestations
  • Stage, and
  • Status (e.g., new, unchanged, improving, resolving)

• Link abnormal laboratory or imaging results to the underlying cause (e.g., hyponatremia is due to the patient's hepatic failure).

• Whenever possible, attribute a patient's clinical presentation to an underlying condition (e.g., the patient's shortness of breath is due to ...)

Click here for documentation improvement tactics for physicians caring for adult patients. Here is the CMS website with additional ICD-10 information for physicians.

Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.

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