Documentation Tip: The Verboten List

Posted on Mon, Jun 27, 2016

Our regular feature of documentation tips for clinicians.

By Timothy Brundage, MD

The following words should be removed from use when documenting in the medical record:

Remove Replace With
"Admit" Status is “inpatient” or “observation”
"Admission Orders" “Initial care orders”
“Delirium” - This term almost made the Hospital Acquired Conditions (HAC) list Consider if there is a causative reversible medical condition that would support the diagnosis of encephalopathy
“Urosepsis” “Sepsis due to UTI”
“Stable” condition Use “fair,” “guarded,” “serious,” “critical” to justify medical necessity
“VSS” or “AF” Must document ALL vital signs. This helps to justify medical necessity and also counts as a component of the PE for E&M coding
Symbols/Arrows ↓Na+ ≠ Hyponatremia
“Post-op” This may be misinterpreted as a complication
“CRI/CRF" “CKD stage 1-5”
“Closed head injury” or “CHI” NO codes exist for this, must be injury specific
“Sharp” debridement May not count as “excisional” depending on the rest of the documentation
“History of...” This is a V code with less severity of illness (SOI) and risk of mortality (ROM)
“Unresponsive” (no code) Unconscious codes to coma
“Altered Mental Status” or “AMS” “Encephalopathy” when clinically appropriate

Timothy Brundage

Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. 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

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