Wiki documentation and coding compliance

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kumeena

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where can I get the documentation guidelines for physician to code for DM uncontrolled.
Some physicians document A1C not at target /DM unc/DM OOC/DM not well controlled etc.,

Unc : Uncontrolled
OOC: Out of controll

Above abbreviations are not approved by our facitlity.

Thank you
 
Unapproved abbreviations

If the abbreviations are NOT approved by the facility then they can not get credit for documenting the condition.

You must impress upon the physicians that their documentation must meet the standard set by the facility. If there IS an approved abbreviation for uncontrolled DM, get that to the physicians so that they can begin using it.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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