Background: Clinical documentation is challenging when patients are admitted with many diagnoses of varying severity. Documentation of chronic or low-acuity conditions on the History and Physical (H&P) note can feel less salient than primary admission diagnoses. This can lead to under-documentation of comorbid conditions and an underrepresentation of the complexity of care. Capturing this overlooked […]

Background: Accurate documentation of the patient’s diagnoses helps to reflect the severity of illness which has several downstream impacts: clinical outcomes data, risk stratification, hospital quality metrics data such as readmission and mortality index, hospital reimbursement. For this reason, our health system has various ongoing initiatives on clinical documentation to improve the specification of certain […]