How to become a super documenter.

6 Tips to become a Super Documenter.

Good documentation is key to capturing a patient’s accurate mobidity and severity of illness. This affects how quality measures are reported about physicians and doctors and it also affects financial reimbursement. This is even truer when it comes to ICD-10. So what are the top secrets to become a great documenter ?

1.       Be clear.

Although some abbreviations are well recognized in medicine, shortcuts, “severe” abbreviations and poor syntax will cause confusion, ambiguity and loss of information. 
What is "pt. wo ac. dcv" anyway?

2.       Be complete.

Include as many diagnoses that the patient has as possible. Why? This describes the patient better for both clinical care and data capture. Also, document the indication for prescribed medications. 
Is that Rocephin for pneumonia or UTI?

3.       Be specific.

Whenever a condition exists, make sure to describe it as soon as possible. The more detail, the better.
Is the heart failure systolic or diastolic ?

4.       Be consistent.

Conflicting documentation between a progress note and discharge summary without some explanation is like a book with the wrong table of contents. The reader will be confused and make the wrong assumptions. 
 So, is the sepsis resolved or just never existed ..? why does the discharge summary say fever and hypotension...

5.       Be the doctor.

What this means, as doctors, we need to interpret the diagnostic studies and labs into actual diagnoses. An abnormal lab without some clinical interpretation is just redundant. Symptoms need to be connected to a cause and sometimes diagnoses need to be connected to each other. 
Everyone knows that the patient has elevated creatinine. But is it ARF or CKD ? or ARF on top of CKD. Is it from diabetes ? 

6.       Be Nice.

... with coders and CDI nurses. Remember, the role of CDI and coders is to help you accurately describe your patients so they look on paper the same as they are in the bed. Any questions or queries that they have for you are not intended to question any medical judgment. Far from it. They want your data to look the best.
"Thank you for responding to the query !"