Nurses Impact on Documentation

Nursing Documentation Has Value

Official coding comes from the provider's documentation.  However, nursing documentation plays a crucial role in supporting the provider's documentation and diagnoses.  In the CDI department, we have observed that certain diagnoses have been denied by insurance companies, prompting us to use nursing documentation to back them up.

Diagnoses Validation

Validating many diagnoses involves two components. The first is objective data, including anthropometrics, lab results, diagnostics, and other quantifiable findings. The second is subjective data, encompassing the provider's observations. Nursing documentation plays a crucial role in strengthening the support for a diagnosis in this area.

Documentation Tips for Nurses:

1. Be clear and descriptive when documenting symptoms.  Your nots and observations are valuable. 

2. Use all available descriptors/symptoms from the drop down in your EMR charting system that are appropriate.

3. Accurate and consistent intake and outputs measurements are essential for validating a multitude of diagnoses, but especially chronic heart failure and kidney failure.

4. Accurate weights using a consistent method at the same approximate time of day is vital for validation.

5. Document the level of edema and indicate whether pitting is noted to further support CHF validation.

   1. If a patient is short of breath, it's crucial to articulate how you determined this and the severity of the condition. Insurance companies may deny claims for respiratory failure if we do not clearly explain the reasons for noting shortness of breath.  Factors to include are:

      1. Accessory muscle use

      2. Tachypnea

      3. Tripoding

      4. Unable to speak in full sentences

The Value of What You Document

If you believe your charting goes unnoticed, reconsider.  The CDI office pays close attention to what you charted not only during the patient's stay but also long after their departure.  Your observation hold significant value as they help documentation integrity and for your organization to receive proper compensation.