Accurate documentation for dying patients

by Trey La Charité, MD
Sadly, there are patients who will not survive their current level of illness regardless of the best efforts of their physicians and their medical facility. The providers caring for these patients are often at risk of underreporting those patients’ severity of illness and risk of mortality.

CDI professionals must educate facilities and physicians about the importance of accurately capturing the entire disease process description because physicians,unfortunately, are frequently reluctant to document additional disease processes in the charts of patients who are obviously about to die. Let’s look at one example before discussing possible causes.