Clinical Documentation Excellence

Documenting and Coding Nephropathy and Chronic Kidney Disease

By Richard Schamp, MD
CEO, Capstone Performance Systems

Definitions
Nephropathy refers to any disease of the kidney. In common clinical parlance, the term is modified by an etiology referring to one of over a dozen types, such as analgesic nephropathy, gouty nephropathy or most commonly, diabetic nephropathy. Chronic Kidney Disease (CKD) is defined by GFR (Glomerular Filtration Rate) less than 60 ml/min per 1.73 m2 and/or kidney damage for three or more months. The presence of albuminuria is most commonly used to…

How Past Conditions Affect Current Documentation and Coding

in Articles Clinical Documentation Excellence Newsletter | tagged: Capstone Performance Systems coding history of documenting history of documenting past conditions

By Jan Deyber, CRN-C, and Tiffany Brookshire, BSN, CRN-C

We often see inconsistency in medical records regarding diagnoses as current or historical. Documenting “history of” when referencing a patient’s past medical background is a longstanding practice. Providers may intend a “present perfect” tense – a condition that started in the past and continues in the present. However, in the world of diagnosis coding, “history of” indicates a past (or past perfect) tense; in other words, a condition that no longer…

Changing Documentation in the Medical Record

in Articles Clinical Documentation Excellence Newsletter

by Richard Schamp, MD, Chief Executive Officer

When documenting in the medical record, providers should take care to capture their thoughts and findings as completely as possible. Best practice is to document the patient encounter at the time, or shortly afterwards. Inevitably, situations require some changes in the medical record, of which four types are recognized. (more…)

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