Documentation Tips Susan Sabu RN, BSN Clinical Document Improvement Specialist Critical Care, Trauma, Cardiology, PACU.

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