Health Information Management Post

A special posting at the request of the folks behind the scenes who help to ensure that our documentation is of the highest integrity. HIM plays a significant role in bringing a level of sophistication to our PowerNotes, helping the health system not only meet coding requirements, but improve the structured templates to facilitate the best means of recording clinical events.

FYI: the information pertains to Hospital-based documentation

A note from Health Information Management –

We would like to thank you for your work and strides with documenting in CIS.
As you are know the details provided in your documentation regarding diagnoses, therapies and procedures - will paint a picture of the patient’s severity of illness, and describes the quality of care provided.

Great documentation will accurately reflect your great work.
Take credit for the excellent care you provide.

We would like to inform you about the “Diagnosis Specificity” field within most CIS progress note templates.
• By utilizing this field you will (with just a mouse click)–
o Identify acute exacerbations of certain chronic conditions
o Document site and stage of decubitus ulcers.
o Stage the level of chronic kidney disease
o Define Diabetic related conditions
Terry Gosselin - Lead Coding Compliance Analyst phone #322-4302

…AND something everyone can appreciate –by using this field you can eliminate a potential post discharge query from coding staff!

REMEMBER…If it is not documented…it did not happen…or did not exist.
So be as specific as possible when documenting.

Thank you!
Jennifer Cavagnac - Senior Documentation and Coding Analyst phone #322-4366
o Provide information useful to case management, quality review, resource utilization, coding, research, and other clinical staff.