1. Onsite Clinical Documentation Improvement Team Martin Conroy Beverly Gebeline Natasha Morley Susan Sabu

2. Comprehensive documentation of patient’s clinical presentation The most likely reason(s) for admission determined after study (not presenting symptoms) Comorbid conditions that complicate care, require management, monitoring, assessment, further evaluation post discharge, and treatment from any healthcare professional in your assessments & plans. Complete and comprehensive description of all services performed. (including bedside services)

3. Uses of your Clinical Documentation Coordination of patient care Severity of Illness (SOI) reporting Risk of Mortality (ROM) reporting Length of Stay (LOS) management Quality reporting (UHC & PHC4) Correct reimbursement Medical necessity of services Justify discharge status Hopefully keep you out of the legal system

4. REQUEST FOR DOCUMENTATION CLARIFICATION: Date of Request: 6-13-14 Patient Name Doe, John MRN: xxxxxxxx Room: 614A Treatment team: Per xxxxxx consult patient has Hypervolemic CHF. Patient takes Lasix 40mg at home, this was changed to Lasix 40mg IV, currently patient receiving Lasix 80mg re: CKD with nephrosis, CHF. If appropriate and we are managing CHF please document CHF as Acute, Chronic, AoC Systolic, Diastolic or Both in progress notes and discharge summary. DO NOT RESPOND ON THIS SHEET: Documentation clarification must occur in the progress notes and be carried through to the discharge summary to consider this issue resolved. Requested by: __Martin Conroy_____Director Clinical Documentation Improvement. If you have any questions, please contact me via email or at 267-235-4238 This sheet is NOT a part of the permanent medical record. REQUEST FOR DOCUMENTATION CLARIFICATION: Date of Request: 6-13-14 Patient Name Doe, John MRN: xxxxxxxx Room: 614A Treatment team: Per xxxxxx consult patient has Hypervolemic CHF. Patient takes Lasix 40mg at home, this was changed to Lasix 40mg IV, currently patient receiving Lasix 80mg re: CKD with nephrosis, CHF. If appropriate and we are managing CHF please document CHF as Acute, Chronic, AoC Systolic, Diastolic or Both in progress notes and discharge summary. DO NOT RESPOND ON THIS SHEET: Documentation clarification must occur in the progress notes and be carried through to the discharge summary to consider this issue resolved. Requested by: __Martin Conroy_____Director Clinical Documentation Improvement. If you have any questions, please contact me via email or at 267-235-4238 This sheet is NOT a part of the permanent medical record. Attention Treatment Team

5. What is not allowed to be coded HGB 6.0, 15 % EF, Pox 88% 2L O2 Radiology findings (pleural effusions or acute pulm. edema post op.) Blood transfusions RX (Lasix, Milrinone, epinephrine) Ventilation (>48 hour post op) Nutrition consults Debridement Name the condition (acute resp. insufficiency) You must document significant findings You must indicate significance You need to document reason (cardiogenic shock/prophylactic ) Acute respiratory distress vs failure Morbid obesity, malnutrition, electrolyte Excisional vs non excisional

6. Coding & Quality reporting requires Detail Symptoms & unspecified diagnoses CHF Respiratory Failure Sepsis/urosepsis/bacteremia Pneumonia COPD/asthma CKD Detailed diagnoses Acute, Chronic, AoC Diastolic, Systolic Acute vs Chronic vs AoC related to surg. Hypoxia vs hypercapnia Septic shock, sepsis due to UTI Aspiration, vent. Related, HIV related Due to gram neg., pneumocytis carinii, influenza Acute exc., status asthmaticus Stage 1-4, ESRD, AKI, ATN

7. Other documentation All chronic conditions from office notes must be carried into inpatient record All acute & chronic conditions must be carried from transferring facilities into the Temple record All diagnoses from non-treating physicians (radiology & pathology) must be carried into the treating teams notes or acknowledged. (wound care, nutrition, radiology, pathology) Clear documentation of whether conditions are present on admission (or ruled out)

8. Things to remember Nothing is assumed or obvious (all relationships must be stated) Listing diagnoses in history does not indicate medical management Symptoms must be named (most likely, presumed, assumed are all acceptable in the face of uncertainty) Treatment team is responsible to clarify any conflicts in documentation

9. Procedure documentation remains the same even if done at bedside or in emergency room Title Depth Instrumentation Technique Size of area debrided post procedure Appearance after procedure Hemostasis Excisional debridement Necrotic muscle #10 scalpel Excised all necrotic 18 cm x 12 cm x 4 cm Healthy tissue with bleeding Achieved with surgical