Tag Archives: documentation

HIM Weekly Update 3/27/2015

HIM Update 3.27

Certificate of Death Worksheet

Please review the pdf below on how to properly fill out a Certificate of Death:

Certificate of Death Worksheet


Box 24-Cause of Death: Disease or Injury

  • Part 1:

    NOT mechanism
    NOT cardiopulmonary arrest or unknown

  • Part 2:

    Contributing Factors

  • Box 29:Manner

    • MDs can only certify if NATURAL death

    Box 30-36

    • ONLY completed by Coroner

    ICD-10 Physician Documentation Education in October 2014

    Centegra Health has partnered The Advisory Board Company to launch an ICD-10 Physician Documentation Education in October 2014.

    Join us for a clinician-led introduction to the importance of ICD-10 and documentation improvement. This session will be focused on how simple word choice has a dramatic impact on the perceived acuity of our patients. Specifically, attendees will benefit from:

    • Getting credit where credit is deserved: accurate reflection of SOI, ROM, and quality scores
    • Strategies for improved documentation supporting SOI and ROM for today that will ease the transition to ICD-10

    We provide excellent care to our patients. This effort is not about changing the way we practice medicine, or demanding that we document more; rather, it’s about getting credit for all that you do and helping us document in a way that captures all the good work we do now as well as in the ICD-10 environment.

    Thank you in advance for taking the time to help Centegra achieve our quality goals.

    Kumar Nathan, MD
    VP, Clinical Effectiveness

    Irfan Hafiz, MD
    VP, Medical Affairs







    10/20/2014 7 to 8am Internal Medicine
    (Internal Medicine, Hospitalists, Family Medicine, Gastroenterology, Hepatology)
    Centegra Hospital-Woodstock 3701 Doty Rd., Woodstock A
    10/20/2014 12 to 1pm Allergy/Immunology
    (Allergy, Immunology, Infectious Disease, Rheumatology)
    Front St. IT Conference Room 213 Front St. McHenry 6
    10/20/2014 6 to 8pm General Surgery
    (General; Trauma;Cardiac; Cardiothoracic; Plastic; Colorectal; Pancreatic; Hepatic; all other surgical specialties)
    Centegra Hospital-Woodstock 3701 Doty Rd., Woodstock A
    10/21/2014 7 to 8am Critical Care
    (Intensivists, Pulmonology, Anesthesia)
    Centegra Hospital-Woodstock 3701 Doty Rd., Woodstock A
    10/21/2014 12 to 1pm Internal Medicine
    (Internal Medicine, Hospitalists, Family Medicine, Gastroenterology, Hepatology)
    Front St. IT Conference Room 213 Front St. McHenry 6
    10/21/2014 6 to 7pm Pediatrics
    (Pediatrics, Newborns, Pediatric Surgery)
    Centegra Hospital-Woodstock 3701 Doty Rd., Woodstock A
    10/22/2014 7 to 8am Emergency Department
    (ED and Urgent Care)
    Centegra Hospital-McHenry 4201 Medical Center Dr., McHenry D
    10/22/2014 12 to 1pm Cardiology Front St. IT Conference Room 213 Front St. McHenry 6
    10/22/2014 6 to 8pm Obstetrics and Gynecology
    (Obstetrics, Gynecology, Surgical, Gynecology, Gynecologic Oncology)
    Centegra Hospital-McHenry 4201 Medical Center Dr., McHenry D
    10/23/2014 7 to 8am Orthopedics/Orthopedic Surgery Centegra Hospital-McHenry 4201 Medical Center Dr., McHenry D
    10/23/2014 12 to 1pm Neurosurgery
    (Neuro-Oncology Surgery, Neurosurgery-spine, Neurosurgery-vascular)
    Front St. IT Conference Room 213 Front St. McHenry 6
    10/23/2014 6 to 7pm Cardiology Centegra Hospital-Woodstock 3701 Doty Rd., Woodstock A

    Finding Visit ID’s for Pre-Registered Patients

    Finding Visit ID’s for patients that are pre-registered for a procedure, study, or surgery can be done in 2 quick steps.

    While inside your census (My Patients or Group & My Patients) switch the Bed Filter and the Pt. Type to ALL and click search.


    Click Picture To Enlarge

    Your census list will be expanded to show “Pre-Reg” patients. Pre-Reg patients are patients that have been pre-registered for imaging studies, procedures, or surgery. The Visit ID will show up in the same place as the admit patients.


    Click Picture To Enlarge

    Please remember to use the Visit ID when dictating.

    For questions or concerns, please contact Michael Millare or Prapti Desai at (815)759-4330.

    Routine Printing Discontinued

    Effective immediately, routine printing of the following transcribed documents will be discontinued:

    • H&P’s
    • Consults
    • Progress Notes
    • Operative Reports
    • PFT
    • ECG
    • EMG
    • Sleep Study
    • Stress Test
    • Cardiac Cath
    • EEG
    • TEE

    In lieu of printing the above documents, please refer to HPF. For questions regarding accessing HPF and viewing documents, please contact Michael Millare or Prapti Desai at (815)759-4330.

    For a printable copy of this memo click here.

    2 Midnight Rule Macro Update

    There are updates to the 2 midnight macros for documentation. All future macros will begin with a period (.). This will allow for consistent naming. The previous 2 midnight macro will continue to work as well.


    The patient is expected to need 2 midnights of inpatient care for the management of (add diagnosis) that is complicated by (add co-morbidities), and who has a significant risk of (add complications) if not hospitalized.


    The patient’s (add S & S or Diagnosis) improved after (add outline of treatment) in less than 2 midnights. Therefore, the patient is being discharged (add date) to (add destination) to follow up with Dr. (add physician) in (add # days) days.

    This is a link to the complete list of macros

    Tips on documenting AMS

    AMS is a term with many potential clinical meanings, but is considered “confusion” when the patient’s medical record is coded.

    To ensure the complexity of care rendered is accurately reported, please consider using the following definitions, when appropriate, rather than the term “altered mental status”.

    • Encephalopathy – Nondegenerative diffuse brain disorder secondary to an underlying process, eg. sepsis, toxic, metabolic, hypertensive, hepatic, anoxic. The hallmark is altered mental state.
    • Delirium – Disturbance of consciousness with reduced ability to focus, sustain, or shift attention. Disorganized thinking, agitation, misperceptions of sensory stimuli, and visual hallucinations.
    • Dementia – Progressive decline in mental processes. Memory impairment , cognitive disturbances, and a disturbance in executive function.
    • Stupor – State of baseline unresponsiveness that requires repeated application of vigorous stimuli to achieve arousal.
    • Coma – State of unresponsiveness in which the patient lies with eyes closed and cannot be aroused, even with vigorous stimulation.
    • TIA – Brief cerebral, spinal, or retinal ischemia without acute infarction. Cerebral Embolus or Thrombus (without infarction) is usually an underlying cause of TIA.
    • Stroke – Neurological Symptoms with evidence of stroke on neuroimaging
    • Aborted Stroke – “Stroke in Evolution” – Transient neurologic symptoms due to ischemia with a normal MRI. Therapeutic efforts (e.g. tPA) may play a role.
    • Psychosis –Disturbance in perception of reality. Delusions, hallucinations, and thought disorganization.


    The diagnoses for inpatients can be written as “possible”, “probable”, “suspected”, “likely” or “rule out”

    Where can I find past immunization history?

    Past information such as immunizations, implants, procedures can be found in the patient profile.

    • Patient profile can be accessed through the reports tab.

    • Now select “Patient Profile” from the drop down menu.

    • Select immunization from the list.


    • The vaccine, dose and administration date should be available.

    Clinical Documentation – when should “history of…” not be used

    “History of” terminology should not be used if condition is currently being treated. “History of” implies the condition no longer exists and treatment is not currently being performed.

    Instead document “Diabetes, being followed by Endocrinologist, no complaints at this time, compensated on Insulin”.

    Commonly non documented conditions

    Remember to document the presence of any medically created openings or limb loss.

    Any patient with any of these conditions has a higher severity of illness than a patient without one.

    Artificial openings

    • Gastrostomy V44.1
    • Colostomy V44.3
    • Tracheostomy V44.0
    • Ileostomy V44.2


    • BKA V49.75
    • AKA V49.76
    • Foot V49.73
    • Toe V49.71 or V49.72

    Vascular conditions

    • AAA – Abdominal aortic aneurysm – 441.1 (w/o repair)
    • Aortic Atherosclerosis – 440.0