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From the Clinical Documentation Team


Actual documentation: "Code Blue called last night."
Best practice documentation: "Code Blue called due to cardiac arrest (or respiratory or cardiopulmonary arrest)." 
Also document cause of the arrest if known.

Actual documentation: “Low sodium, replaced." 
Best practice documentation: "Hyponatremia, replaced." 

Actual documentation: "Elevated trop, likely demand." "Elevated trop, likely type 2"
Best practice documentation: "Elevated trop, likely demand ischemia." "Elevated trop, likely NSTEMI type 2"

REMEMBER: Always answer CDI queries (They are here to help you!). Any questions for the clinical documentation team, please call Jean Banzhof, 717-544-4426.

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