Always be as specific as possible regarding the acuteness of the clinical issue. Problems are usually acute, chronic or acute on chronic.

Always include if the problem is mild, moderate or severe. Staging of the problem is very useful.

If the problem has been resolved, continue to mention it in subsequent progress notes, with the clarification that the problem was been resolved.

Marco A. Ramos MD, CCDS

In order to quote from this post (using Chicago style) please use the following:

Marco A. Ramos, “Clinical Documentation Improvement Series #15. Clinical Documentation Improvement Series #15. General Advise (Tip #2)”, SMO Blog (blog), September 9, 2019, https://steemit.com/health/@secondmedicalop/clinical-documentation-improvement-series-15-general-advise-tip-2

Links to the Previous Posts in this Series

- Clinical Documentation Improvement Series #1. Documenting Acute Respiratory Failure

- Clinical Documentation Improvement Series #2. How and When Do We Use the Body Mass Index (BMI)

- Clinical Documentation Improvement Series #3. Is it Delirium or Encephalopathy?

- Clinical Documentation Improvement Series #4. Documenting Myelopathies and Radiculopathies

- Clinical Documentation Improvement Series #5. Documenting Electrolyte Imbalances.

- Clinical Documentation Improvement Series #6. Documenting Electrolyte Imbalances.

- Clinical Documentation Improvement Series #7. Documenting Electrolyte Imbalances.

- Clinical Documentation Improvement Series #8. The Importance of “Present on Admission”

- Clinical Documentation Improvement Series #9. If the Patient has Elevated Troponins...

- Clinical Documentation Improvement Series #10. Documenting Pneumonia

- Clinical Documentation Improvement Series #11. If the Patient Has Not Eaten for Several Days Before Admission…

- Clinical Documentation Improvement Series #12. Documentation of Acute Renal Failure

- Clinical Documentation Improvement Series #13. Documenting Liver Failure

- Clinical Documentation Improvement Series #14. Clinical Documentation Improvement Series #14. Tips for Documenting the Organism Causing Pneumonia #1