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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