Category Archives: Clinical documentation

When is it appropriate to document “history of…”?

As physicians we frequently document past medical conditions with the phrase “history of…”. An example of this would be:

John Doe is a 54 yr old man with history of congestive heart failure who presents with worsening shortness of breath and increased leg swelling.

Though this documentation makes sense to any physician reading this it is not correct by CMS coding guidelines.

According to CMS coding guidelines “history of…” is referring to a condition that is no longer receiving any treatment.

For example 38 yr old man with a history of right tibial fracture in 1995 now presents with fever cough and expectoration. The history of tibia fracture indicates that the patient is no longer receiving treatment for the tibial fracture and is therefore appropriate documentation.

Another example: Jane Doe is a 67 yr old female with a history of hypertension presents with chest pain and is on metoprolol would not be correct as the hypertension is still being treated with the metoprolol even if it is controlled. This distinction is very important to correctly attribute the severity of illness for your patient.

A common mistake is to use the term “history of CHF…” This should be documented as “known CHF currently compensated..” or uncompensated as the case may be.

Have you seen the new formatted ED reports?

ED notes viewed in Paragon have had an improved formatting making the documents much easier to review.

Please review the “Nurse clinical” and “Physician clinical” documents located in the ED folder in HPF for ED nursing and ED physician notes respectively.

T systems ED notes in HPFNew ED progress note

CDI Tip of The Month: Pneumonia

Below is a link to the CDI Tip of the Month. This month the CDI tip is Pneumonia.

Pneumonia

Clinical Documentation Tips: Anemia, Congestive Heart Failure, and Diabetes

Please view the tips below brought to you by our CDI team:

Anemia

Congestive Heart Failure

Diabetes

ICD-10 Kick-off Information

On April 27th & May 26th Centegra’s HIM department conducted a presentation Kicking-off ICD-10. Dr. Janowtiz, from BCBS, also presented on May 26th regarding ICD-10. Below are the links to the presentations by Centegra HIM and Dr. Janowitz.

ICD-10 Overview by: Centegra Health System

ICD-10: Preparing for the Challenges Ahead by: Robert Janowitz, MD

ICD-10 Learning Opportunities for May

Each month, Centegra will provide education for physicians and their office staff to help ease the transition to ICD-10. We scheduled another kick off session due to requests from those who missed the presentation in April. You may attend one or both of these programs below, but please note we request RSVP as seating is limited.

“REPEAT” KICK OFF TO ICD-10

This is an opportunity to learn general information about ICD-10 from the Centegra Health Information Management Team.
Date: Tuesday, May 26
Time: 11am-Noon (box lunch provided)
Location: Centegra Hospital-Woodstock, Conference Rooms A & B

ICD-10: PREPARING FOR CHALLENGES AHEAD

Why does ICD-10 matter? What is changing for physicians and hospitals? How do I get ready? How will you prepare? These and other questions will be answered by our presenter, Dr. Robert Janowitz, Medical Director for Blue Cross Blue Shield Illinois Local Markets.

Date: Tuesday, May 26
Time: Noon-1pm (box lunch provided)
Time: Centegra Hospital-Woodstock, Conference Rooms A & B

RSVP by May 21
Danette Santana, Physician Outreach
815-788-5859 /dsantana@centegra.com