DOCUMENTATION IMPROVEMENT TIPS

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Presentation transcript:

DOCUMENTATION IMPROVEMENT TIPS USE YOUR DISCHARGE SUMMARY TO FOCUS ON THE DIAGNOSES Final Diagnosis not clearly stated Non-specific diagnosis used. (example: CHF only instead of acute/chronic/diastolic/systolic) Final diagnosis not listed Other diagnoses treated not listed on DC summary CLEARLY STATED Discharge Summary needs: PRINCIPAL/FINAL DIAGNOSIS: DEFINED AS THE CONDITION, ESTABLISHED AFTER STUDY, TO BE CHIEF REASON FOR ADMISSION ALL OTHER DIAGNOSES: CONDITIONS THAT COEXIST AT TIME OF ADMIT/DEVELOP SUBSEQUENTLY/AFFECT TREATMENT OR NEED CLINICAL EVALUATION, THERAPEUTIC TREATMENT, DIAGNOSTIC PROCEDURES-- EVEN IF RESOLVED BY DISCHARGE. CLARIFY WHICH DIAGNOSES ARE PRESENT ON ADMISSION Documentation Specialists: (name/phone #)