Improve predicted mortality rates through documentation

An 89-year-old female is admitted to the hospital from home with a ST segment elevation myocardial infarction (STEMI). She also has stage 3 chronic kidney disease and refuses catheterization due to risk of dialysis. The patient enacts her living will. She is given appropriate medical therapy, but Sunday night at 3 a.m., her MI extends suddenly, and the blocked artery of the STEMI has re-stenosed. The woman passes away by 4 a.m.

Death certificate documentation does not allow for documentation of the dying process or the mode of death. Instead, death certificates require that a cause of death be noted generally the principal diagnosis). Ironically, documenting the cause of death is not enough under the MS-DRG system. Instead, we need to focus on the dying process