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6 Best Tips to Boost Your Documentation Process: Tip 4

Posted on Thu, May 01, 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

4. UTI vs. Urosepsis vs. Sepsis

Urosepsis is synonymous with UTI. Documenting the term “urosepsis” is ambiguous and nonspecific for coding purposes (Coding Clinic, 1988 1st Quarter).

Your patient should appear as sick on paper as they are in the bed. Are the signs of SIRS or acute organ dysfunction present? Consider documenting “probable sepsis” or “severe sepsis due to UTI.”

UTI Documentation Graphic

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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