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6 Best Tips to Boost Your Documentation Process: Tip 3

Posted on Thu, Apr 24, 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

3. CoPD

COPD is the ninth most-denied admission diagnosis by the RAC. COPD is a chronic condition and should not be admitted to the hospital unless one of these issues is present:

  • Acute Exacerbation
    • Document acute exacerbation of COPD if admission is medically necessary and IV steroids and frequent nebulization treatments are required.
  • Acute Respiratory Failure – frequently the actual reason for the admission
    • Document with the clinical criteria are present
      • Requires two of the following three
        • Respiratory Distress – document this in the physical exam
        • PaO2 is less than 60 mmHG (pulse ox is less than 88 percent) or higher oxygen requirements for COPD patients on oxygen
        • PaCO2 is greater than 50 mmHg with a pH less than 7.5 (means acute)
  • Chronic Respiratory Failure is commonly a missed diagnosis associated with COPD
    • Home oxygen is greater than 16 hours a day (not just nighttime oxygen)
    • PaCO2 is greater than 50 when pH isn’t greater than 7.35 (means chronic)

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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