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Documentation Tip of the Week: AMI

Posted on Wed, Jun 03, 2015
Documentation Tip of the Week: AMI

Our weekly segment featuring documentation tips for clinicians

DID YOU KNOW?

Acute MI will default to STEMI

AMI documentation must be more specific to either STEMI or NSTEMI

  • Always document the SITE of the MI if known (anterior wall, inferior wall)
  • Always document the AGE of the MI
    • ICD-10 uses 4 weeks to distinguish between ACUTE and old MI (previously 8 weeks with ICD-9)
    • Subsequent myocardial infarction is an MI after 4 weeks

Remember - Hospital documentation can include “probable, likely or suspected” diagnoses

Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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