Consistency in Diagnosis Documentation
In the previous post of this series, I outlined the importance of using terms like “probable,” “possible,” “likely,” and “not ruled out” when documenting in a medical chart. In this post, I will highlight the importance of maintaining consistency with diagnoses throughout the medical record.
Be consistent throughout the record
In clinical practice, as noted earlier, providers often make decisions and place orders based on a probable diagnosis. As the hospitalization progresses and more clinical data becomes available, these preliminary diagnoses may be confirmed, modified, or excluded. That evolution needs to be clearly documented.
For example, if “probable pneumonia” is noted on day one, and by day two the condition has been excluded, it should be documented as “pneumonia was ruled out.” This communicates to the medical coder that the initial suspicion is no longer valid, and helps justify the discontinuation of antibiotics or other resources. This level of clarity ensures the record reflects accurate clinical reasoning and resource use.
Document when a condition resolves
In longer hospital stays, it’s common for initial problems to resolve during the course of care. When this happens, it is good practice to continue listing the diagnosis in the assessment section, but with the addition of “resolved.” For example: “Hyponatremia. Present on admission, resolved.”
This documentation serves two purposes. First, it informs future providers that the patient experienced a problem which is no longer active. Second, it impacts coding: “resolved” confirms the condition was treated and required care, while “ruled out” indicates the condition was never present and thus should not impact resource justification.
Marco A. Ramos, MD, CCDS
Board-Certified in Internal Medicine & Nephrology
Certified Clinical Documentation Specialist
