Title: 
Headings: Commonly Asked Physician Clinical Documentation Questions
Commonly
 
Asked
 
Physician
 
Clinical
 
Documentation
 
Questions
 

Q:
 
What
 
portions
 
of
 
the
 
patient
 
record
 
are
 
most
 
important
 
regarding
 
the
 
documentation
  
I
 
provide?
  

Q:
 
Are
 
the
 
diagnostic
 
test
 
results
 
contained
 
in
 
the
 
chart
 
sufficient
 
for
 
coding?
  

Q:
 
Should
 
I
 
restate
 
the
 
consulting
 
provider’s
 
diagnosis
 
again
 
as
 
an
 
attending
 
provider?
   

Q:
 
If
 
I
 
have
 
a
 
patient
 
with
 
many
 
different
 
diagnoses,
 
do
 
I
 
need
 
to
 
document
 
all
 
of
 
them?
 

Q:
 
When
 
should
 
“suspected,”
 
“possible”
 
or
 
“probable”
 
be
 
used?
  

How
 
should
 
I
 
document
 
a
 
diagnosis
 
that
 
I
 
have
 
ruled
 
out?
 

Q:
 
How
 
should
 
the
 
problem
 
list
 
be
 
most
 
effectively
 
utilized?
  

Q:
 
What
 
if
 
I
 
disagree
 
with
 
a
 
diagnosis
 
from
 
a
 
consult?
  

Q:
 
If
 
a
 
consultant’s
 
diagnosis
 
needs
 
clarification,
 
does
 
the
 
consultant
 
receive
 
the
 
query
 
or
 
the
 
attending
 
physician?
 

Q:
 
What
 
do
 
I
 
do
 
if
 
I
 
was
 
not
 
the
 
attending
 
physician
 
in
 
the
 
time
 
period
 
that
 
the
 
query
 
refers
 
to?
 

Q:
 
Why
 
can’t
 
another
 
group
 
of
 
people
 
complete
 
notes
 
for
 
us?
 

Q:
 
I
 
thought
 
you
 
cannot
 
do
 
debridement
 
without
 
excising?
 

RVUs?
  

Q:
 
How
 
will
 
the
 
coders
 
and
 
CDIP
 
nurses
 
know
 
that
 
doctors
 
have
 
improved
 
their
 
clinical
 
documentation?
 

Q:
 
How
 
do
 
I
 
receive
 
feedback
 
on
 
the
 
accuracy,
 
completeness
 
and
 
specificity
 
of
 
my
 
clinical
 
documentation?
  

Q:
 
What
 
do
 
I
 
do
 
if
 
current
 
T-sheets
 
do
 
not
 
have
 
enough
 
room
 
to
 
allow
 
me
 
to
 
accurately
 
reflect
 
the
 
documentation
 
required?
  

Q:
 
How
 
do
 
I
 
document
 
complications
 
or
 
untoward
 
events
 
that
 
occur
 
in
 
surgery?
   

Q:
 
What
 
tools
 
does
 
Seton
 
have
 
that
 
can
 
help
 
me
 
document
 
more
 
accurately
 
and
 
completely?
 


Content: A: The
 
skills
 
and
 
principles
 
you
 
learn
 
in
 
documentation
 
coaching
 
and
 
via
 
interaction
 
with
 
the
 
CDIP
 
Nurses
 
impact
 
the
 
accuracy
 
and
 
completeness
 
of
 
clinical
 
documentation
 
in
 
all
 
settings. While
 
the
 
activities
 
of
 
the
 
CDIP
 
Nurses
 
directly
 
impact
 
coding
 
and
 
billing
 
by
 
the
 
hospital,
 
consistency
 
of
 
coding
 
and
 
billing
 
between
 
hospital
 
and
 
professional
 
will
 
become
 
ever
 
more
 
crucial
 
as
 
payers
 
coordinate
 
their
 
adjudication
 
of
 
facility
 
(e.g.,
 
hospital)
 
billing
 
with
 
claims
 
submitted
 
by
 
professionals
 
for
 
the
 
same
 
episode
 
of
 
care. Inconsistency
 
between
 
the
 
two
 
types
 
of
 
claims
 
(Professional
 
and
 
Hospital)
 
may
 
result
 
in
 
decreased
 
or
 
denied
 
reimbursement
 
to
 
one
 
or
 
both
 
parties. Q: How
 
will
 
the
 
coders
 
and
 
CDIP
 
nurses
 
know
 
that
 
doctors
 
have
 
improved
 
their
 
clinical
 
documentation? The
 
coders
 
will
 
assign
 
codes
 
to
 
the
 
highest
 
degree
 
of
 
specificity
 
based
 
on
 
the
 
documentation
 
within
 
the
 
medical
 
record. Increased
 
accuracy