When it comes to certain medical conditions, we all have wrestled with the conflagration of differing opinions and the discrepancies in provider documentation.
A common example: The emergency department physician states sepsis, the attending physician writes pneumonia, and the infectious disease specialist documents viral infection. What gives? CDI specialists need to address these situations head on to obtain accurate, specific, and clear documentation. Why do these discrepancies occur and how can we address them?
Though medical schools may vary in how they teach clinical indicators, they follow generally recognized standards and guidelines for clinical practice. These standards are established by professional medical organizations and are based on evidence-based medicine and clinical research.