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6 Best Tips to Boost Your Documentation Process: Tip 2

Posted on Thu, Apr 17, 2014

Helpful TipsGood 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. In this 6-part series, each Thursday, I’ll be sharing my most recent documentation tips.

by: Timothy N. Brundage, M.D., CCDs

2. Acute MI ICD-10 Update
Acute MI will default to STEMI. AMI documentation must be more specific to either STEMI or NSTEMI. ICD-10 Guidelines dictate that all unspecified AMI will default to STEMI.
• AMI type 2 must be further specified to NSTEMI
• Unspecified AMI default to STEMI could negatively affect quality metrics
• Always document the site of MI if known (anterior wall, interior wall, etc.)
• Always document the age of the MI
• ICD-10 uses four weeks to distinguish between acute and old MI (previously eight weeks with ICD-9)
• Subsequent myocardial infarction is an MI after four weeks

BrundageTimothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine

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