You may be frustrated by the need to choose specific words about diagnoses that seem obvious to you without these descriptors. But accurate documentation can make a huge difference in your hospital’s bottom line and published metrics. Understanding the relative impact of changing your terminology can help you make these changes, until the language becomes second nature. Your hospital administrators will be grateful – and you just might cut down your queries!
Dr. Rajda is medical director of clinical documentation and quality improvement for Mount Sinai Hospital in New York, and medical director for DRG appeals for the Mount Sinai Health System. She serves as assistant professor of medicine at Icahn School of Medicine at Mount Sinai. Dr. Fatemi is an assistant professor at the University of New Mexico, Albuquerque. She is director of documentation, coding, and billing for the division of hospital medicine at UNM. Dr. Reyna is assistant professor in the division of hospital medicine and medical director for clinical documentation and quality improvement at Mount Sinai Medical Center.
