Tip: Accurate documentation for terminal patients
by Trey La Charité, MD
CDI professionals must educate facilities and physicians about the importance of accurately capturing the entire disease process 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.
- “I don’t want to ‘penalize’ the patient.”
- “I don’t want to bilk the insurance company.”
- “I don’t want to stick the family with a higher bill.”
- “It just doesn’t feel right.”
- “Why do you need that? They are going to die. How much sicker do you need them to look?”
Editor’s Note: This article is an excerpt from the April 2013 edition of CDI Journal. La Charité is a hospitalist with the University of Tennessee Hospitalists at the University of Tennessee Medical Center at Knoxville, and an ACDIS Advisory Board member. He is board certified in internal medicine and has been a practicing hospitalist since 2002. Contact him at clachari@utmck.edu.