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:
Properly documenting chronic conditions is essential because:
How to improve documentation of chronic conditions
To capture the patient’s chronic conditions in the medical record, please be sure to:
|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.