Top 10 ICD-10 Documentation Tips

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Need to document:
1. Laterality: left vs right for bones, organs, blood vessels, strokes, injuries, etc.
2. Status of disease: Acute vs. Chronic vs. Acute on Chronic
3. Anatomy: Specific bone in hand or foot, lobe of lung, exact blood vessel
4. Location of Insult: AMI of anterior wall, Left MCA stroke, etc.
5. Medical Linkage: Acute Blood Loss Anemia due to GI bleed, UTI due to indwelling Foley catheter, CKD stage 3 due to DM, Cirrhosis due to Hep C, Sepsis due to Pneumonia, etc.
6. Associated &/or related conditions: DM with hyperglycemia and retinopathy, Cirrhosis with ascites and esophageal varices, etc.
7. Gustilo-Anderson Scale for Fractures
8. Glascow Coma Scale for encephalopathic or comatose patients
9. Alcohol/Specific Drug/Nicotine dependence with or without withdrawal
10. Present on Admission: Anything captured in PMH or A/P sections of H&P is considered POA

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