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

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

3. 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

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

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

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

7. 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???????????????

8. GI NPO TPN, TF BMI 30 Abnormal labs GIB

9. GU/Renal Elevated creatinine Urosepsis Urinary retention Hematuria

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

11. Systemic Infection/Inflammation Bacteremia Sepsis Severe sepsis Shock

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

13. ICD 10 Thank you Susan