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Tips to Boost Your Documentation Process: Hypercoagulable State

Posted on Wed, Jan 28, 2015
Tips to Boost Your Documentation Process: Hypercoagulable State

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.

Hypercoagulable State
Hypercoagulable state is often missed in either documentation and/or coding. If chronic anticoagulation is used to prevent new clots, these likely treat a hypercoagulable state and should be documented. Hypercoagulable state is a comorbidity/complication (CC) and helps reflect the severity of illness in patients. Remember to use “possible,” “probable” or “still to be ruled out.”

Primary Hypercoagulable States (CC):

  • Factor V Leiden
  • Protein C deficiency
  • Protein S decifiency
  • AT3 deficiency

Secondary Hypercoagulable States (CC):
  • Active Cancer
  • Chemotherapy
  • Myeloproliferative disorders
  • HIT
  • Nephrotic syndrome
  • Oral contraceptives
  • Sickle cell disease / crisis
  • Pregnancy / Postpartum
  • Wegener granulomatosis
  • DIC
  • Estrogen receptor modulators (tamoxifen, raloxifene)
  • Antiphospholipid antibodies

Remember to use “possible,” “probable” or “still to be ruled out.”

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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