The 2 most powerful words in clinical documentation
May 12, 2015 | VIA BLOG | Posted 11:16 PM by Dr. Jon Elion

With all due respect to those who do an outstanding job designing and conducting comprehensive educational programs related to Clinical Documentation Improvement (CDI), a good deal of what doctors needs to know about improving their documentation can be reduced to two simple words: “Due to”.

A typical doctor’s note often contains a recitation of observations, symptoms, findings and facts, but often lacks a description of the relationship between any two of them. In many cases, the relationship is implied and, to a medical person, is obvious. But coders cannot code from the “implicit” — they need specifics.

Perhaps the best way to clarify the power of “Due to” is with an example. Here’s an actual note from a chart, copied and pasted directly from the electronic medical record, including spelling mistakes:

Assessment Plan

1.high k- resolved- I am very worried about gi bleed – needs stolls- ? gi consult

2.esrd- hd for wed

3.avr- on hep> coumadine

4.bradycardia- resolved

pt follows diet and goes to dial- he has high k , dropped hb, abd pain>>?? gi bleed????

This note could take up an entire day in a CDI educational workshop, just dissecting the problems and creating approaches to query the physician for clarification of what is meant. Let’s look at some of the areas in need of improvement:

● high K — the physician should interpret the lab finding, and say “hyperkalemia”. What was the hyperkalemia due to??

● AVR — as a Cardiologist, I know that this refers to an aortic valve replacement. Since this appears to affect the patient’s anticoagulation regimen, a more complete description of the prosthetic valve type would be appropriate.

● Bradycardia — both aortic prostheses and hyperkalemia can produce heart blocks — was that the cause of the bradycardia? What was it due to?

● DM — this no doubt refers to Diabetes Mellitus. A more complete description (Type I, Type II, insulin usage, etc.) is needed. If this is secondary diabetes (no indication yet that it is), it should be stated what it is due to.

● Dropped hb — this needs to be interpreted (“anemia”) and an explanation provided of what it is due to. If it is from the GI bleed, this needs to be stated (post-hemorrhagic anemia).

● GI bleed — this needs to be described more completely, and it should include what it is due to.

Okay, you get the idea. This note would be helped immensely by the generous use of “due to” by the notewriter. And, by the way, I have two other phrases that I love to use in my notes. The first is “manifested by… ” (kind of the opposite of “due to”); the second is “indications include…” (this one is directed more at medical necessity, but it helps to make a note that completely documents your thinking).

So, that’s not by any means a complete list of what is needed to improve clinical documentation, but it is easily communicated, easily remembered, and helps to make massive improvements in clinical note-writing. Due to — if you are a care-giver, use it, if you are working with physicians to help them improve their notes, educate them!

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