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.