Documentation Tips Susan Sabu RN, BSN Clinical Document Improvement Specialist Critical Care,...
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Transcript of Documentation Tips Susan Sabu RN, BSN Clinical Document Improvement Specialist Critical Care,...
![Page 1: Documentation Tips Susan Sabu RN, BSN Clinical Document Improvement Specialist Critical Care, Trauma, Cardiology, PACU.](https://reader036.fdocuments.us/reader036/viewer/2022062519/5697bfce1a28abf838ca99bd/html5/thumbnails/1.jpg)
Documentation Tips
Susan Sabu RN, BSNClinical Document Improvement Specialist
Critical Care, Trauma, Cardiology, PACU
![Page 2: Documentation Tips Susan Sabu RN, BSN Clinical Document Improvement Specialist Critical Care, Trauma, Cardiology, PACU.](https://reader036.fdocuments.us/reader036/viewer/2022062519/5697bfce1a28abf838ca99bd/html5/thumbnails/2.jpg)
Who’s your audience?
• Who do you write your notes for?
![Page 3: Documentation Tips Susan Sabu RN, BSN Clinical Document Improvement Specialist Critical Care, Trauma, Cardiology, PACU.](https://reader036.fdocuments.us/reader036/viewer/2022062519/5697bfce1a28abf838ca99bd/html5/thumbnails/3.jpg)
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
![Page 4: Documentation Tips Susan Sabu RN, BSN Clinical Document Improvement Specialist Critical Care, Trauma, Cardiology, PACU.](https://reader036.fdocuments.us/reader036/viewer/2022062519/5697bfce1a28abf838ca99bd/html5/thumbnails/4.jpg)
Labs
• Hemoglobin/transfusion• WBC- Present on admission• Platelet• Sodium/Potassium• Creatinine• Glucose• INR
![Page 5: Documentation Tips Susan Sabu RN, BSN Clinical Document Improvement Specialist Critical Care, Trauma, Cardiology, PACU.](https://reader036.fdocuments.us/reader036/viewer/2022062519/5697bfce1a28abf838ca99bd/html5/thumbnails/5.jpg)
Neuro Assessment
• AMS• Delirium• Agitated• Lt sided weakness 2/2 CVA
![Page 6: Documentation Tips Susan Sabu RN, BSN Clinical Document Improvement Specialist Critical Care, Trauma, Cardiology, PACU.](https://reader036.fdocuments.us/reader036/viewer/2022062519/5697bfce1a28abf838ca99bd/html5/thumbnails/6.jpg)
Cardiac Assessment
• A-fib• Heart failure, EF 15%• HTN• CTNI elevated• STEMI• CP????????????
![Page 7: Documentation Tips Susan Sabu RN, BSN Clinical Document Improvement Specialist Critical Care, Trauma, Cardiology, PACU.](https://reader036.fdocuments.us/reader036/viewer/2022062519/5697bfce1a28abf838ca99bd/html5/thumbnails/7.jpg)
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???????????????
![Page 8: Documentation Tips Susan Sabu RN, BSN Clinical Document Improvement Specialist Critical Care, Trauma, Cardiology, PACU.](https://reader036.fdocuments.us/reader036/viewer/2022062519/5697bfce1a28abf838ca99bd/html5/thumbnails/8.jpg)
GI
• NPO• TPN, TF• BMI <18; >30• Abnormal labs• GIB
![Page 9: Documentation Tips Susan Sabu RN, BSN Clinical Document Improvement Specialist Critical Care, Trauma, Cardiology, PACU.](https://reader036.fdocuments.us/reader036/viewer/2022062519/5697bfce1a28abf838ca99bd/html5/thumbnails/9.jpg)
GU/Renal
• Elevated creatinine• Urosepsis• Urinary retention• Hematuria
![Page 10: Documentation Tips Susan Sabu RN, BSN Clinical Document Improvement Specialist Critical Care, Trauma, Cardiology, PACU.](https://reader036.fdocuments.us/reader036/viewer/2022062519/5697bfce1a28abf838ca99bd/html5/thumbnails/10.jpg)
Skin
• Wound R/T?• Ulcer R/T?• Rash• I&D
![Page 11: Documentation Tips Susan Sabu RN, BSN Clinical Document Improvement Specialist Critical Care, Trauma, Cardiology, PACU.](https://reader036.fdocuments.us/reader036/viewer/2022062519/5697bfce1a28abf838ca99bd/html5/thumbnails/11.jpg)
Systemic Infection/Inflammation
• Bacteremia• Sepsis• Severe sepsis• Shock
![Page 12: Documentation Tips Susan Sabu RN, BSN Clinical Document Improvement Specialist Critical Care, Trauma, Cardiology, PACU.](https://reader036.fdocuments.us/reader036/viewer/2022062519/5697bfce1a28abf838ca99bd/html5/thumbnails/12.jpg)
Coding for Cardiology
• CHF• CAD• MI• Cath/PTCA/CABG• Arrhythmias
![Page 13: Documentation Tips Susan Sabu RN, BSN Clinical Document Improvement Specialist Critical Care, Trauma, Cardiology, PACU.](https://reader036.fdocuments.us/reader036/viewer/2022062519/5697bfce1a28abf838ca99bd/html5/thumbnails/13.jpg)
ICD 10
Thank you
Susan