Before finishing the note – last minute documentation tip

Before signing off on your note remember to think of the following that can significantly impact your severity of illness.

  • What is the cause of anemia?
  • Leukocytosis cause?
  • Is there right heart failure with the cor pulmonale?
  • Pulmonary edema – cardiogenic or non-cardiogenic?
  • Heart failure or not?
  • Is there acute or chronic osteomyeilitis?
  • Are there any pressure ulcers?
  • Is there malnutrition?