7 Criteria to Follow for Clinical Documentation Improvement (Part 2): Reliability & Precision

Posted: Jun 08 2015


In the first segment on clinical documentation, we discussed reasons why high quality clinical documentation is increasingly important. Specifically, we covered the first of seven criteria: Legibility. This article is the second in a series of 4 that will focus on criteria two & three: Reliability & Precision.

Criteria #2: Reliability

Reliable documentation will yield the same result each time it is repeated. For example, when a patient undergoes certain treatments, or specific diagnostic studies are ordered, does the stated diagnosis appear to be supported based on interventions?

If the patient has received antibiotics, but no infection process is stated, then the rationale for receiving the antibiotic is not supported. The physician must be queried as to the clinical condition that would support the drug administration. In this case, the initial documentation did not meet reliability.

Criteria #3: Precision

In order for documentation to meet precision, it must contain sufficient detail to support the condition(s) of the patient.

For example, the final diagnosis is stated as pneumonia, but the chest x-ray interpretation by the radiologist states indicative of bronchitis. We do not have a consensus between physicians as to the final diagnosis of the patient. In these types of situations, the managing physician is responsible for the final determination and must be queried as to whether he/she is in agreement with bronchitis.

What interventions is the patient receiving? What if the managing physician states “shortness of breath: asthma vs bronchitis”? Coding rules guide us to code the symptom, then both possible diagnoses. The initial documentation did not meet precision.

Click here to read Part 3 of the Clinical Documentation Improvement Series.


About the Author

Ms. Dorothy Steed, CCS, CDIP, CPC-H, CPCO, CPUM, CPUR, CPHM, CPMA, ACS-OP, CCS-P, RCC, RMC, CEMC, CPC-I, CFPC, PCS, FCS, CPAR, has 38 years of experience in both hospital and physician billing, coding, reimbursement and claims management, specializing in Medicare requirements. Ms. Steed is credentialed in medical coding, compliance, utilization management, utilization review, medical auditing, clinical documentation improvement and patient accounts.


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