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The importance of documenting chronic conditions
June 7, 2019

This article is for all physicians, nurse practitioners, and physician assistants.

Chronic conditions are those that last more than three months and can’t be prevented by vaccines or cured by medication. If a patient’s chronic condition will impact care and medical decision-making, it should be clearly documented and the status reported at every visit.

When treating patients with chronic conditions, ask these questions to ensure that you accurately document all conditions:

  • Does the patient have any chronic conditions that impact the way you make medical decisions about their care and how you manage it, or their treatment?
  • How do coexisting conditions affect the way this patient is cared for during this visit?
  • What other chronic conditions affect the patient every day?

Properly documenting chronic conditions is essential because:

  • It ensures that all providers have a complete picture of the patient’s current health status.
  • It helps the patient’s plan predict future healthcare needs, including quality and care management programs.

How to improve documentation of chronic conditions
To capture the patient’s chronic conditions in the medical record, please be sure to:

  • Update problem lists and past medical history to reflect active chronic conditions.
  • Clearly indicate that these lists have been updated each time the patient receives care (such as “reviewed on day/month/year” or “updated on day/month/year”) so your coding staff can determine what diagnoses to report.
  • Not report conditions that no longer exist. Instead, report conditions as “history of” when appropriate.
  • State the patient’s diagnosis to help your coding staff capture all active diagnosis codes; for example, “has chronic obstructive pulmonary disease (COPD),” “is diabetic,” “with hypertension (HTN),” “complicated by chronic kidney disease (CKD.)”
  • Document a patient’s reason for follow up clearly. Include not only the patient’s reason for the current visit, but other conditions impacting the patient every day that were reviewed. For example:
Instead of Use
Chief complaint - here for follow-up. Chief complaint - here for follow-up on DM, HTN, CHF

When treating patients with chronic conditions for an acute health issue
Because the patient’s chronic condition affects the acute condition treatment, it is appropriate to consider the chronic conditions and code them on the date you care for the acute health issue. For example, if a patient has an acute visit for an upper respiratory tract infection and also has a chronic condition such as diabetes, you would consider the patient’s current diabetes medications before you prescribe an over-the-counter cough suppressant.

Detailed documentation of chronic conditions should clearly depict disease severity, comorbidities, underlying disease processes, and other factors that contribute to the level of complexity for the patient encounter. The ICD 10 CM Guidelines state:

"Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care, treatment or management."

Clear, concise and detailed documentation of chronic conditions improves continuity of care and ensures that the conditions are reported accurately.


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