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Documentation Tip of the Week: 10 Tips for ICD 10

Posted on Wed, May 20, 2015
Documentation Tip of the Week: 10 Tips for ICD 10

ICD 10 is scheduled for implementation in October 2015. Here's what clinicians need to know to document properly. 

Need to document:

1. Laterality: left vs. right

2. Stage/Episode of Care: initial, subsequent & sequela

3. Stage of Disease: acute vs. chronic vs. acute on chronic; severity of pressure ulcer

4. Specific Anatomy: specific bone in the hand, R lobe of lung, etc.

5. Associated and/or Related Conditions: diabetes with manifestation

6. Type of MI along with Myocardium involved: anterior wall, etc. and specific coronary artery

7. Seizure specificity: type, if intractable and if with status epilepticus

8. Glasgow coma scale and Dominant vs. Non-Dominant Side for Strokes

9. Nicotine dependence: state product and if any nicotine induced disorder

10. Gustilo-Anderson Scale for fractures & Glasgow coma scale for comatose patients


  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 DrBrundage@gmail.com.

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