Vascular surgery charts often include findings (clinical indicators) of conditions which increase the patient’s Risk of Mortality (ROM) and, if documented as a Diagnosis (in progress notes and discharge summary), will increase the coded Severity of Illness (SOI).
When these diagnoses are included in the notes and discharge summary, the SOI will increase significantly, and physicians will get credit for the care of their very sick patients.
Be sure to document a diagnosis for every: abnormal test result, condition monitored, consultation/drug/treatment ordered, and/or (suspected) etiology.
Remember: Uncertainty is acceptable for inpatients if documented.
• Possible/probable/likely/suspected
Download the complete tip, Vascular Surgery-CCs and MCCs.