Recent Blogs Posts

I recently handed out the Physician Documentation Improvement Pocket Guides to my docs and my Pediatricians asked if there was specific criteria for SIRS in the pediatric population. Temp and increased WBC and the increase in bands probably stays the same, but the increase in HR >90 or RR>20 would obviously be different. What information can I give them. Is there a different pocket guide for pediatricians? And if not, what criteria changes are there for their documentation?

Have a patient that has been diagnosed with right heart failure 2nd to secondary pulm hypertension due to phen/phen. I was told by a cardiologist that in order to have right heart failure you would have left heart failure. He wanted me to use the RHF as principal diagnosis. The patient had an elevated BNP, fluid overload, weight gain, and further elevated JVP. Since the pulm hypertension is the underlying cause of this wouldn't it be appropriate to use the pulm hypertension as principal diagnosis? ...

In the September issue of "Today's Hospitalist", there was an article titled, "Beware of Leading Queries". Documentation Specialists have a special role in today's hospital environment and it was discouraging to see that the"wrong" intention of Documentation Improvement programs was represented by this article. Physicians who read this article may not be aware of the importance of a quality Documentation Integrity Program and the improved data it can bring to a hospital. ...

Originally posted by Lucian Newman III, MD on ComplyMD

It never occurred to me before to be concerned about “specificity of documentation.” I was busy and it seemed not to matter on the surface.

This concept was not taught in medical school or residency. I would never devote the time to learn how to do it. What changed?

– Perhaps it was the criticism of U.S. medicine that we consider to be the best in the world.
– Perhaps it was the alleged ...

After the recent presentation Jennifer Avery of HCPro and I gave on the ethical reporting of sepsis, we were regaled by several comments from totally opposite perspectives. They ranged from a listener who insisted that the only people admitted to inpatient status with an infection HAD to have sepsis to ones who recognized that the overcoding of sepsis was causing a massive impact on diluting the impact of severity of illness and risk of mortality of the septic patient.

There were ...