Tag 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.

How to document in the correct encounter using Paragon 13.x

Documenting using physdocs on the wrong patient encounter will result in inaccurate documentation. Please make sure you document in the correct encounter.

Find the patient

Find your patient using the earch function in the upper right hand corner

Include all patients in the search

If the patient is discharged then make sure the “include active only” is unchecked.

Look for additional encounters

If your patient has additional encounters they will show up as “additional visits” in the lower right hand corner of the card.

Open list of encounters

Clicking on the “additional encounters” link will open all the additional encounters for that patient. Individual encounters can be opened by clicking on the patient name in the encounter.

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

Clinical Documentation Tips: CHF

In order to ensure capture of current diagnoses they must be documented within the progress notes AND the discharge summary. Diagnoses pertinent to the current visit must be documented in progress notes and carried through to the discharge summary. Including all diagnoses preceded by the words “ possible, probable, resolved, resolving, suspected, improved, improving, likely”.

Chf tip

For a printer friendly version please click here.


Attention Office Managers/Coders

UPDATE: Session is Full

What: Kick Off to ICD-10


When: Monday, April 27, 2015; 12pm-1pm

*Box Lunch Provided*

There will be monthly ICD-10 learning sessions. Please contact Danette Santana, Physician Outreach
(815)788-5859/ dsantana@centegra.com, for more information.

Reminder: Electronic CDI Queries

CDI queries are now electronic. The queries will now show up in a physician’s deficiency tab under Missing Text.

Please fill out the information at the space provided at the bottom of the document. Click into the box to input information before completing the deficiency.

Below is an example of what the queries will look like.
CDIClick to enlarge

For questions or concerns, please contact the EMR Physician Support Liaisons at (815)-759-4330.