Documentation Tips Susan Sabu RN, BSN Clinical Document Improvement Specialist Critical Care, Trauma, Cardiology, PACU

Who’s your audience? Who do you write your notes for?

Simple Everyday Techniques “INK IT” Write Clearly & Legibly Addendum/ Update Document Write reason UTO Abbreviations PICTURE OF YOUR PATIENT Primary diagnosis for admission after testing

Labs Hemoglobin/transfusion WBC- Present on admission Platelet Sodium/Potassium Creatinine Glucose INR

Neuro Assessment AMS Delirium Agitated Lt sided weakness 2/2 CVA

Cardiac Assessment A-fib Heart failure, EF 15% HTN CTNI elevated STEMI CP????????????

Pulmonary assessment Home O2, COPD OSA,CPAP O2 sat <88% on RA;Increased work of breathing; Nasal flaring, retractions, hypoxia, cyanosis PNA VDRF TEST RESULTS: Xray/CT SOB???????????????

GI NPO TPN, TF BMI 30 Abnormal labs GIB

GU/Renal Elevated creatinine Urosepsis Urinary retention Hematuria

Skin Wound R/T? Ulcer R/T? Rash I&D

Systemic Infection/Inflammation Bacteremia Sepsis Severe sepsis Shock

Coding for Cardiology CHF CAD MI Cath/PTCA/CABG Arrhythmias

ICD 10 Thank you Susan