Documentation and coding of severe sepsis matters in terms of patient risk assessment and establishing sepsis as a diagnosis, as well as the effect of such documentation (and subsequent code assignment) on quality measures.
Paul Evans, RHIA, CCS, CCS-P, CCDS, manager of regional clinical documentation and coding integrity at SutterHealth in San Francisco, California, offers this sample heart failure query form which includes educational definitions of heart failure, cardiomyopathy and other related concerns. This query originally appeared on the ACDIS website.