RE: [EXTERNAL] RE:Documentation with no clinical support
Katy,
All to true. But I have done it and continue to educate the doc's that
if you are going to make even a presumptive diagnosis you need to
document how you came to it. All that good clinical thought process.
The battle continues J
Robert
Robert S. Hodges, MSN, BSN, RN, CCDS
Clinical Documentation Improvement Specialist
VHA CDI Council Member
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence
("I CARE")
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative,
Agile, Integrated
"We are dealing with Veterans, not procedures; With their problems, not
ours." --General Omar Bradley
All to true. But I have done it and continue to educate the doc's that
if you are going to make even a presumptive diagnosis you need to
document how you came to it. All that good clinical thought process.
The battle continues J
Robert
Robert S. Hodges, MSN, BSN, RN, CCDS
Clinical Documentation Improvement Specialist
VHA CDI Council Member
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence
("I CARE")
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative,
Agile, Integrated
"We are dealing with Veterans, not procedures; With their problems, not
ours." --General Omar Bradley