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6 Best Tips to Boost Your Documentation Process: Tip 5

Posted on Thu, May 08, 2014

documentationGood 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

5. “to Cover”

Documenting “to cover” for gram negative rods does not code to gram negative pneumonia.

Do not document:

Pneumonia – will Rx Zosyn “to cover” for gram negative rods

Consider instead:

“Possible” gram negative rod pneumonia – will Rx Zosyn

The term “to cover” does not code to the diagnosis. However, documenting a “possible” diagnosis is acceptable language in a hospital setting.

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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6 Best Tips to Boost Your Documentation Process: Tip 6

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6 Best Tips to Boost Your Documentation Process: Tip 2

6 Best Tips to Boost Your Documentation Process: Tip 1

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