Get Ready! Improve your Clinical Documentation!

It is time to start improving your clinical documentation to prepare your practice for ICD-10.

Select the codes most often used in your practice. Now, you need to determine if your current documentation is sufficient to support ICD-10. It would be best to assume it is not, since ICD-9 was not as specific as ICD-10. For example, you did not need to include laterality, now you must include which side of the body is affected (i.e. right, left, or bilateral).

Keep in mind a few of the examples below, and prepare your clinical notes to include the specific information needed to accurately code some common diagnoses:

Diabetes Mellitus:

Fractures:

Injuries:

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