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Tips to Boost Your Documentation Skills: Acute MI

Posted on Wed, Feb 18, 2015
Tips to Boost Your Documentation Skills: Acute MI

Clinical Documentation Improvement Tip of the Week

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. 


Acute Myocardial Infarction Differential diagnosis of “Troponinemia” (partial list)

  • AMI
  • Acute PE
  • Acute Heart Failure
  • Myocarditis
  • ESRD
  • Aortic Dissection
  • Sepsis in Critically Ill
  • Shock
  • Cardio-toxic chemotherapy
  • Rhabdomyolysis
  • Stroke & SAH
Regardless of what release mechanism, Troponinemia is not benign and is associated with poor prognosis. Providers (cardiologists) must indicate the clinical significance. Query the provider for clinical relevance if necessary. CAD

 
No SOI Low SOI   High SOI 
CAD, Angina, Demand Ischemia  Unstable Angina, Impending MI Acute MI 
Troponin Leak ACS w/ + troponins  NSTEMI



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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