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Clinical Documentation Handbook

Clinical Documentation Specialists (CDS) perform concurrent reviews of inpatient medical records and query providers for:

  • Clinical indicators for a diagnosis but no documentation of a condition
  • Clinical evidence for a higher degree of specificity or severity
  • A cause and effect relationship between two conditions or organisms
  • An underlying cause when admitted with symptoms
  • Documentation of treatment without a corresponding diagnosis
  • Clarification of conflicting documentation in the chart

Principal Diagnosis

The condition established after study to be chiefly responsible for occasioning the admission.​

Secondary Diagnosis / Comorbid Conditions

Additional conditions present at the time of admission or developed while in the hospital that affects the care path for the patient or current hospital episode.

  • Clinical evaluation
  • Therapeutic treatment
  • Diagnostic procedures
  • ​Extended length of hospital stay
  • Increased nursing care and/or monitoring

Documentation of secondary conditions affects the patient severity of illness profile.

Treatment Plan

Problem lists should be updated with each inpatient hospitalization.

All medications and treatments should have a corresponding diagnosis.

All diagnoses should be documented consistently in the progress notes with a clear treatment plan.

Signs and symptoms should be defined by underlying diagnoses if known.

Coding Guidelines State

  • Medical record coders are not allowed to infer or make a diagnosis.
  • Abnormal lab values, abnormal diagnostic tests, and pathology findings must be interpreted and the clinical significance must be documented by the provider (MD, DO, NP or PA).
  • In the absence of a definitive diagnosis, document as possible, probable, likely or suspected. The suspected diagnosis that was treated can be coded.​

Discharge Summary

Establish and/or validate diagnoses:

  • All conditions evaluated or treated should be reflected in the discharge summary.
  • Consulting providers’ diagnoses should be acknowledged by the treating team.
  • State when a differential diagnosis was ruled out.
  • Specify if a condition was present on admission.

Present on Admission (POA)

It is important to clearly document if a condition was POA; if unable to determine if a condition was POA, document as such.

Certain conditions if not POA are perceived as an indicator of poor care. Make documentation clear and ensure true depiction of care is reflected in coding.

Hospital Acquired Conditions (HACs)

Considered to be "preventable."

If the condition was NOT present on admission it is categorized as "provider-preventable."

HACs as of 2015:

  • Pressure ulcers Stage III and IV
  • Injuries from falls and trauma
  • Surgical site infections (after orthopedic or bariatric surgery)
  • Object left in surgery
  • Air embolism
  • Blood incompatibility
  • Catheter associated infections
  • Manifestations of poor glycemic control
  • Mediastinitis after CABG
  • DVT or PE after orthopedic procedures

General Documentation Tips

If you receive a query and there is no definitive diagnosis or clinical significance, respond and let the Clinical Documentation Improvement (CDI) team know.

  • Avoid documenting symptoms without an associated diagnosis (if known)
  • Link symptoms to the underlying etiology/cause