What else

Introduction into the "What Else" approach in documentation

Whenever documenting a clinical condition, it's helpful to follow the "What Else" rule. This rule is simply a mental pause and asking yourself: "What else do I document about this condition ?"

Let's put it to the test:

89 yo patient presents for dyspnea, tachypnea, crakles, hypoxia, needs BiPAP and you find out that it's caused by heart failure. He's know to have chronic heart failure

You start with "Congestive Heart Failure " 

Then need to pause and ask 

What else ?

Acute Congestive Heart Failure

What else ?

Acute Systolic Congestive Heart Failure

What else ?

Acute Systolic Congestive Heart Failure on top of Chronic Systolic Congestive Heart Failure

What else ?

Acute Hypoxic Respiratory Failure secondary to Acute Systolic Congestive Heart Failure on top of Chronic Systolic Congestive Heart Failure


Applying the "What Else" concept guarantees an accurate depiction of the severity of illness of patients and their Risk of Mortality in a much superior way than "CHF" 

Keep that in mind