Menu

Blog Posts

Documentation tips

Documentation Tips: Teaching Interns and Residents

Posted on Mon, Mar 27, 2017
Documentation Tips: Teaching Interns and Residents

Our recurring series of documentation tips for clinicians.

By Timothy Brundage, MD

A countersignature by itself is insufficient for both documentation and billing purposes.

Acceptable Documentation

According to CMS, at minimum, the following documentation must be included when billing for services provided by the intern/resident with a teaching physician:
 

  • "I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident's note and agree with the documented findings and plan of care."
  • "I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident's note."
  • "I saw and evaluated the patient. I reviewed the resident's note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”

Unacceptable Documentation

Unacceptable documentation by a teaching physician includes the following examples with a countersignature:
 
  • “I saw and evaluated the patient”
  • “I reviewed the resident’s note and agree with the plan”
  • “Agree with the above...”
  • "Patient seen and evaluated...”
  • “Discussed with resident and agree with plan...”

Resources:
Brundage.png

Timothy Brundage, MD, CCDS, is a hospitalist 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 medical degree 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.

Share    

Documentation Tip: Heart Failure - Framingham Criteria

Posted on Wed, Aug 24, 2016
Documentation Tip: Heart Failure - Framingham Criteria

Our recurring series of documentation tips for clinicians.

By Timothy Brundage, MD

Reduce risk of denial for CHF admissions using the Framingham Criteria for CHF diagnosis.  

Document these each and every time along with the following:
 

  • Acute/Chronic (both)
  • Systolic/Diastolic (both)

Framingham Criteria:

Major
 
  • Acute pulmonary edema
  • Cardiomegaly
  • Hepatojugular reflex
  • Neck vein distension (JVD)
  • Paroxysmal nocturnal dyspnea or orthopnea
  • Rales
  • Third heart sound gallop

Minor
 
  • Ankle edema
  • Dyspnea on exertion (DOE)
  • Hepatomegaly
  • Nocturnal cough
  • Pleural effusion
  • Tachycardia (>120bpm)

* Heart failure is diagnosed when two major criteria or one major and two minor criteria are met.

Reference: http://www.aafp.org/



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.

Share    

Documentation Tip: The Verboten List

Posted on Mon, Jun 27, 2016

Our regular feature of documentation tips for clinicians.

By Timothy Brundage, MD

The following words should be removed from use when documenting in the medical record:
 

Remove Replace With
"Admit" Status is “inpatient” or “observation”
"Admission Orders" “Initial care orders”
“Delirium” - This term almost made the Hospital Acquired Conditions (HAC) list Consider if there is a causative reversible medical condition that would support the diagnosis of encephalopathy
“Urosepsis” “Sepsis due to UTI”
“Stable” condition Use “fair,” “guarded,” “serious,” “critical” to justify medical necessity
“VSS” or “AF” Must document ALL vital signs. This helps to justify medical necessity and also counts as a component of the PE for E&M coding
Symbols/Arrows ↓Na+ ≠ Hyponatremia
“Post-op” This may be misinterpreted as a complication
“CRI/CRF" “CKD stage 1-5”
“Closed head injury” or “CHI” NO codes exist for this, must be injury specific
“Sharp” debridement May not count as “excisional” depending on the rest of the documentation
“History of...” This is a V code with less severity of illness (SOI) and risk of mortality (ROM)
“Unresponsive” (no code) Unconscious codes to coma
“Altered Mental Status” or “AMS” “Encephalopathy” when clinically appropriate
 


Timothy Brundage

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.

Share    

Documentation Tip: Functional Quadriplegia

Posted on Wed, Jun 01, 2016
Documentation Tip: Functional Quadriplegia

By Timothy Brundage, MD

Definition: "Complete immobility due to frailty or severe physical disability”

Documentation of this ailment adds to the Severity of Illness (SOI) of the patient. Functional Quadriplegia is not true paresis, but inability to move due to another medical condition.

Documentation example: Complete immobility due to severe weakness from Multiple Sclerosis; Functional Quadriplegia due to end-stage dementia.

The patient is functionally the same as a paralyzed person who requires total care from nursing including feeding.

Read more about Functional Quadriplegia

Brundage.png

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.

Share    

Documentation Tip of the Week: Discharge Summaries

Posted on Wed, Jul 01, 2015
Documentation Tip of the Week: Discharge Summaries

Our weekly feature of documentation tips for clinicians

The Joint Commission has established standards (Standard IM.6.10, EP 7) outlining the components that each hospital discharge summary should contain:

  • Reason for hospitalization: Chief complaint, including a description of the initial diagnostic evaluation
  • Significant findings: Admission and discharge diagnoses (as well as those conditions resolved during hospitalization)
    • All diagnoses documented in coding based diagnostic language
    • List all possible and probable diagnoses in the discharge summary
  • Procedures and treatment provided: Consults, procedure findings, surgical findings, test results, etc.
  • Patient’s discharge condition: How the patient is doing at time of discharge
  • Patient and family instructions: Includes discharge medications, follow up needed, list of all medications changed and/or discontinued, dietary needs, follow up tests or procedures
  • Attending physician’s signature and date of service
The Discharge Summary should not introduce new information, nor should it conflict with previous documentation substantiated in the record.
 
*Remember that most records are coded and billed within 24 hours of the patients discharge*
Studies have demonstrated a trend toward a decreased risk of readmission when the discharge summary arrives before the outpatient follow-up visit takes place. The study, by van Walraven and colleagues (J Gen Intern Med. 2002; 17:186-192), found a 0.74 relative risk of decreased rehospitalization for these patients.

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.

Share    
< Previous Results 1 - 5 of 10 Next >