Limited Documentation
(may not reflect severity of illness) | Complete Documentation
(better reflects severity of illness) |
Chest X-ray shows increasing
pulmonary congestion;
will treat with IV Lasix 40 mg x 1 | Chest X-ray shows pulmonary edema c/w congestive heart failure,
requiring treatment |
Hct = 29 in a patient with black stools;
Transfuse 3 units pRBCs | Need to document diagnosis
justifying the transfusion as
acute blood loss anemia |
Diabetic admitted on Glucotrol;
BS 400; will start NPH and SS insulin. | Document type of diabetes
& whether controlled:
Type II Diabetes Mellitus,
poorly controlled |
Diagnosis of “Urosepsis” for patient
with UTI and clinical signs of sepsis | Sepsis with UTI describes a
septic patient with an
associated or coexisting UTI |
Principle discharge diagnosis
of chest pain | State suspected cause of
the chest pain, if known
(e.g., CAD, GERD |
Nursing home patient with Alzhiemers
Ds, seizure disorder and feeding tube,
admitted with sudden onset of
SOB/fever; CXR reveals RLL infiltrate;
will start Flagyl/Ampicillin. | Need to document that
likely aspiration
pneumonia will be treated
with antibiotics |
Please be sure to respond to all Nurse Documentation Specialists queries, by describing all diseases and conditions you are treating (either known or suspected) in the medical record. This will allow us to more consistently capture the overall severity of illness for BWH inpatients. If questions arise, please contact Andrew Sussman, MD (ext. 26240), Michael Gustatson, MD (ext. 28894), or Christine Dutkiewicz (ext. 27799).