Physicians are encouraged to continue dictating notes, in addition to fulfilling Paragon Electronic Hospital Medical Record requirements. Dictated notes contain more robust documentation to support medical necessity and severity of illness. The benefits of dictated H&P, progress notes, consultations and operative notes are as follows:
Improved communication to your colleagues, which is evidence-based best practice for better patient care and outcomes
Makes documentation more complete, more succinct, faster and easier
Ensures adequate documentation of the essential components to support your E/M codes
Facilitates accurate hospital coding and helps prevent inadvertent down-coding or fraudulent up-coding
Defends medical necessity
For more information, please contact Linnea Thennes, supervisor of clinical documentation improvement for Centegra Health System. She may be reached by calling 815-759-8193 or emailing firstname.lastname@example.org.
Using symbols such as Na↑ is widely understood as hypernatremia among medical professionals but did you know that according to Medicare rules that it cannot be used for valid documentation. In order for a diagnosis to be coded for the admission it must be spelled out. So instead of listing Na↑ in the assessment, remember to write hypernatremia.
When chronic conditions are listed in the assessment without any documentation in the progress note they lack support for being added to the case mix index. Therefore each condition listed in your assessment, must have documented a status for each. Example: “CHF-Stable compensated, Pt on Digoxin”