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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
  • Encephalopathy
  • Functional Quadriplegia or Complete Immobility
  • Malnutrition
  • Obesity and Morbid Obesity
  • Renal Failure, Acute
  • Renal Failure, Chronic
  • Respiratory Failure, Acute
  • SIRS, Sepsis, Severe Sepsis, and Septic Shock
  • UTI and CAUTI

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