Documentation Strategies to Support Severity of Illness

Written by well-known physician educator Robert S. Gold, MD, this handbook covers 32 of the most troubling conditions in documentation today. Dr. Gold provides physicians with the documentation details they need to properly express severity of illness and complexity of medical decision-making.

Each order includes 25 copies so you can hand them out to physicians throughout your facility, or use them to support physician training and presentations. The small handbook format allows your physicians to keep their copies nearby at all times.

Benefits:

• Quick reference guide
• Easy to follow, simple language explaining complex or confusing documentation
• Excellent aid for formulating effective physician queries

Topics covered include:

• Acute Myocardial Infarction
• Adverse Effects of Medications
• Alcohol/Substance Use/Abuse
• Anemia
• Chest Pain/Angina
• Chronic Obstructive Pulmonary Disease
• Comfort Measures Only
• Comorbidities (Comorbid Conditions)
• Complications (Postoperative)
• Coronary Artery Disease
• Debridement
• Dementia/Delirium/Encephalopathy
• Femur Fracture—Treatment
• Gastrointestinal Bleed
• Heart Failure
• Hyperglycemia
• Low Anterior Resection
• Malignancies
• Malnutrition
• Obesity
• Pneumonia
• Pulmonary Edema
• Renal Failure
• Respiratory Failure
• Seizures
• Sepsis
• Stroke/Cerebrovascular Accident
• Symptoms
• Syncope
• Trauma

This 2nd edition of the bestselling handbook for physicians contains twice the content of the first edition and is thoroughly updated.

New conditions added:

• Comfort measures only
• Post-operative complications
• Delirium
• Obesity

Also new to this edition:

• Expanded/more detailed documentation guidance
• Clinical criteria and mechanisms of each disease
• Updates to reimbursement processes

About the Author:

Dr. Gold is known nationally for his education presentations regarding the clinical orientation of coding in AHIMA and HCPro audioconferences. He has spoken at national and state-level Healthcare Financial Management Association and Healthcare Compliance Association meetings about the participation of the medical staff in documentation improvement programs. He writes the monthly columns Clinically Speaking for Briefings on Coding Compliance Strategies and Minute for the Medical Staff for Medical Records Briefing. Dr. Gold also is a cofounder of DCBA, Inc., a consulting company that provides physician-led programs in Clinical Documentation Improvement, with training of CDI Specialists and with coder education in the diagnoses and procedures to which they assign codes.

• Handbooks

• Other Case Management Products
• Other Clinical Documentation Improvement Products
• Other Health Information Management Products