Documentation Myths and Misconceptions

lprescott1lprescott1
in Clinical & Coding
A simple question- I need examples of documentation misconceptions you have heard from your providers- attendings and medical residents... things like "since the DRG is based one diagnosis- I dont elaborate on history and comorbidities..it doesnt matter." or "The attending can just read my note and sign it to indicate he was involved..."

Comments

  • jmccorkl@stanfordhealthcare.orgjmccorkl@stanfordhealthcare.org
    • Attending provider reluctance to restate a diagnosis documented by a consultant - "I'm not a (name a specialty) doctor, I'm not comfortable saying that diagnosis."
    • Attending provider not acknowledging other ancillary assessments and documenting a diagnosis. For example, Wound Care RN identifies a wound, describes it in detail & attaches photos ... Provider: "What more is there to say?" and so does not mention the wound anywhere.
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    Reluctance of Attending to comment on potential conditions noted by other clinicians when care is transferred, particularly amongst Hospitalist.  (1st hospitalist defers clarification to current Attending, and current Attending defers back to 1st Hospitalist.  Neither will comment on potential conditions no longer present, but potentially recognized, managed and resolved during the encounter).
  • lprescott1lprescott1
    jmccorkl@stanfordhealthcare.org said:
    • Attending provider reluctance to restate a diagnosis documented by a consultant - "I'm not a (name a specialty) doctor, I'm not comfortable saying that diagnosis."
    • Attending provider not acknowledging other ancillary assessments and documenting a diagnosis. For example, Wound Care RN identifies a wound, describes it in detail & attaches photos ... Provider: "What more is there to say?" and so does not mention the wound anywhere.

    Thank you- thatone makes you want to scream doesnt it?
  • lprescott1lprescott1
    paul_evans_90314 said:
    Reluctance of Attending to comment on potential conditions noted by other clinicians when care is transferred, particularly amongst Hospitalist.  (1st hospitalist defers clarification to current Attending, and current Attending defers back to 1st Hospitalist.  Neither will comment on potential conditions no longer present, but potentially recognized, managed and resolved during the encounter).

    thanks paul- this is a ocmmon issue I hear in my travels.
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