Documentation Tip of the Week: Atrial Fibrillation

Posted on Thu, Jun 05, 2014

Good documentation is important for new physicians astips well as veteran caregivers. While documentation-tips-graphic.pngdocumenting 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

Atrial Fibrillation Definitions

  • Paroxysmal A. Fib: terminates within 7 days
  • Persistent A. Fib: sustained > 7 days and is subject to rhythm control (e.g. metoprolol, flecanide, amiodarone) to maintain NSR
    • This is a Comorbid Condition (CC) and demonstrates Severity of Illness (SOI)
  • Permanent (chronic) A. Fib: NSR cannot be sustained and physician/patient cease further attempts to maintain NSR
  • History of Atrial Fibrillation: A. Fib in the past but now NSR and taking no medication to maintain NSR
atrial-fib.png brundage-(1).pngTimothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine.


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