The Verboten List

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The following words should be removed from use when documenting in the medical record:

Remove from Documentation Replace with Effective Documentation
Respiratory Insufficiency Acute Respiratory Failure
Renal Insufficiency Acute Renal Failure
Troponinemia/Troponin Leak Type 2 MI or NSTEMI or STEMI
Urosepsis Sepsis due to UTI
Sepsis Syndrome Sepsis
Bacteremia (in a septic patient) Septicemia
Uncontrolled hypertension (accelerated/Malignant) Hypertensive

Urgency, emergency and/or crisis

Post Op Clarify if the issue is a surgical complication
Sharp debridement Excisional debridement
“History of” Chronic or active diagnosis
Unresponsive Unconscious codes to coma
Stable Fair, guarded, serious, critical
Delirium Encephalopathy

Support the severity of illness of your patient using high quality coding based documentation.

Download the complete tip, The Verboten List.