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6 Best Tips to Boost Your Documentation Process: Tip 6

Posted on Thu, May 15, 2014

documentation tipsGood 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

6. Nicotine Withdrawl

Nicotine dependence with withdrawal is a comorbid condition (CC) and impacts Severity of Illness (SOI). When applicable, document “nicotine withdrawal” when you prescribe a nicotine patch for your patients.
  • Note any evidence of withdrawal
  • Note the date of last tobacco use if known

Always remember – Hospital documentation can include “possible, probable, likely or suspected” diagnoses.

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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Comments
Richard, MD
These hints (Pearls) are excellent! The TX Medical Board commonly recommends "8 hours of Medical Records CME" ... Do you know of any on-line or other CME courses which might fulfill this definition?
7/2/2014 10:28:42 AM

Tim Brundage, MD
Yes, suspected fracture is diagnosis that can be coded in the INPATIENT setting. Possible, probable, likely and suspected diagnoses can be captured by coding. Obviously, the physician should try to clarify prior to DC whether or not a fracture is present and can then document this. It is not essential, however, and if the diagnosis is still "suspected" as discharge it should be listed as such on the DC summary.
please email me for the reference
DrBrundage@gmail.com
7/2/2014 10:28:16 AM

MG
Just a question: where Dr. Brundage says 'hospital documentation can include "possible, probable, likely or suspected diagnoses"' does that mean it is acceptable to list the diagnosis (e.g.list dx. as "fracture") when that is only the 'suspected' diagnosis or does that mean that it is permissible (most hospitals say it insn't) to list the diagnosis as, e.g. "suspected fracture"
7/2/2014 10:27:39 AM