Tips to Boost Your Documentation Process: Secondary Diagnoses

Posted on Wed, Sep 10, 2014

Good 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.

by: Timothy N. Brundage, M.D., CCDs

Secondary Diagnoses

A secondary diagnosis is a condition that coexists at the time of admission, develops brundage.png subsequently or that affects the treatment received and/or length of stay of the patient. Remember that secondary diagnoses support the severity of illness (SOI) and show that your patient is as sick on paper as they are in the bed.

Secondary diagnoses are defined as those conditions that consume one of the following hospital resources:

• Clinical evaluation

• Therapeutic treatment Further evaluation by diagnostic studies, procedures or consultation Extended hospital length of stay (LOS)

• Increased nursing care and/or other monitoring

For example, if you are monitoring tele and continuing home amiodarone, DO NOT document “history of A. Fib.”This would meet the criteria for the secondary diagnosis of chronic A. Fib and coders cannot code a “history of.”

Timothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine.

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