Documentation Tips

Susan Sabu RN, BSNClinical Document Improvement Specialist

Critical Care, Trauma, Cardiology, PACU

Who’s your audience?

• Who do you write your notes for?

Simple Everyday Techniques

• “INK IT”• Write Clearly & Legibly• Addendum/ Update• Document• Write reason • UTO• Abbreviations• PICTURE OF YOUR PATIENT

• Primary diagnosis for admission after testing

Labs

• Hemoglobin/transfusion• WBC- Present on admission• Platelet• Sodium/Potassium• Creatinine• Glucose• INR

Neuro Assessment

• AMS• Delirium• Agitated• Lt sided weakness 2/2 CVA

Cardiac Assessment

• A-fib• Heart failure, EF 15%• HTN• CTNI elevated• STEMI• CP????????????

Pulmonary assessment

• Home O2, COPD• OSA,CPAP• O2 sat <88% on RA;Increased work of breathing;

Nasal flaring, retractions, hypoxia, cyanosis• PNA• VDRF• TEST RESULTS: Xray/CT• SOB???????????????

GI

• NPO• TPN, TF• BMI <18; >30• Abnormal labs• GIB

GU/Renal

• Elevated creatinine• Urosepsis• Urinary retention• Hematuria

Skin

• Wound R/T?• Ulcer R/T?• Rash• I&D

Systemic Infection/Inflammation

• Bacteremia• Sepsis• Severe sepsis• Shock

Coding for Cardiology

• CHF• CAD• MI• Cath/PTCA/CABG• Arrhythmias

ICD 10

Thank you

Susan