Let's talk about another problem in Medical coding.
2) Poor documentation.
In essence, poor documentation is anything that inhibits a clear presentation of a patient's story. For instance, if a provider is documenting congestive heart failure, he or she will need to include the acuity and type of congestive heart failure to ensure the highest level of specificity, Instead of just documenting congestive heart failure, which is unspecified, he or she could document acute on chronic systolic congestive heart failure, which would take the diagnosis to the highest level of specificity. All other notes should reflect care and treatment to support the acute on chronic systolic congestive heart failure.
While that may seem like a minor issue of semantics to those outside—and even some inside—the health care system, its potential ramifications are real and significant. The ramifications of poor documentation are endless, They start at the front line and, most importantly, with patient safety issues. From there, the opportunities flow into financial repercussions for the facility. The consequences of poor documentation all come full circle.