Tag Archives: documentation

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

Documentation of metastatic disease

When documenting a case with metastatic disease remember to document to location of the mets.

“Colon cancer with metastasis to bone” codes higher severity of illness than “colon cancer with mets” without mention of location.

Btw do not document “history of metastatic colon cancer” – this cannot be coded at all. By the rules a condition with “history of” is no longer present and is not requiring current treatment.

General rule of thumb is if a patient is receiving active treatment for a condition then it should never be documented as “history of”.

Remember: dictation helps physicians and patients

Dictate notes in addition to Paragon

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 lthennes@centegra.com.

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?

Present on admission – documentation

If any of the conditions listed below are not documented in the admission H&P they are considered hospital acquired conditions.

  • Foreign object retained after surgery
  • DVT & PE post orthopedic procedure
  • Manifestations of poor glycemic control
  • Vascular catheter infection
  • Pneumothorax with venous catheter
  • Falls, fractures, dislocations, intracranial injuries, crush injuries, burns, electrical shock
  • Air embolism
  • Catheter associated UTI
  • Stage 3 or 4 pressure ulcer – important
  • Surgical site infections post CABG, orthopedic procedures or bariatric surgery


The H&P – documentation tips

  • Indicate acuity even when it is obvious such as congenital, chronic, acute, acute on chronic, acute exacerbation etc.
  • Detail pathology that lead to admission or surgery.
  • List every disease or conditions that are present on admission including those that are suspected.
  • Document the significance and interdependence of coexisting conditions

Is it okay to use symbols in documentation?

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.

Clinical documentation – documentation of chronic conditions

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”