Document Detail

Language is key in clinical documentation.
MedLine Citation:
PMID:  21630557     Owner:  NLM     Status:  In-Process    
Medical language and coding language are not the same, which means that physicians often write what they learned in medical school to describe a patient's condition: if it doesn't contain the proper language, the coders can't accurately code the chart. Educate physicians to use appropriate language to reflect the condition of the patient. Look for hints in documentation by other clinicians that the physician documentation might not be accurate. Ensure that documentation is complete to indicate major complication/comorbidity rates (CCs or MCCs).
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Hospital case management : the monthly update on hospital-based care planning and critical paths     Volume:  19     ISSN:  1087-0652     ISO Abbreviation:  Hosp Case Manag     Publication Date:  2011 Jun 
Date Detail:
Created Date:  2011-06-01     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  9603097     Medline TA:  Hosp Case Manag     Country:  United States    
Other Details:
Languages:  eng     Pagination:  84-6     Citation Subset:  H    
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