View as a webpage
More clarification helps your documentation: Definitions!
By Roni Finney, RN CCDS, clinical documentation improvement specialist, HIM
We’re learning that standard definitions aren’t being used regularly by providers. This list will help you – and reduce our need to send you a query.
The following Common Diagnoses definitions have been adopted by Salem Health for specific documentation purposes. Look for them on the Epic tab, upper screen in drop-down box under Standard Definitions.
Each definition gives a clear picture of what is needed for documentation in the medical record. As you use these definitions, your documentation will become more accurate.
Look for definitions for these conditions:
- Acute Myocardial Infarction
- Diabetes Mellitus
- Functional Quadriplegia or Complete Immobility
- Obesity and Morbid Obesity
- Renal Failure, Acute
- Renal Failure, Chronic
- Respiratory Failure, Acute
- SIRS, Sepsis, Severe Sepsis, and Septic Shock
- UTI and CAUTI