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Tips to Boost Your Documentation Process: Heart Failure

Posted on Wed, Feb 04, 2015
Tips to Boost Your Documentation Process: Heart Failure

By Timothy N. Brundage M.D., CCDs

Good documentation is important for new physicians as well as veteran caregivers. While documenting can seem like a very straightforward skill, there are often “best practices” that can be utilized. As a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, FL I write a “weekly documentation tip” email to help physicians improve their clinical documentation. I also share these documentation strategies with the residents I teach.   

Heart Failure
“Coding Clinic,” a published guideline for coders, determined that “Heart Failure with reduced Ejection Fraction” cannot be coded as “Systolic Heart Failure.” Also, “Heart Failure with preserved Ejection Fraction” cannot be coded as “Diastolic Heart Failure.”

Physicians must, at some point in the chart, document “systolic” or “diastolic” to capture the specificity of the heart failure correctly. “Acute,” “chronic” or “acute on chronic” must also be documented.

ABOUT THE AUTHOR
Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, FL. 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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