Documentation best practices: Pathologies of the brain

By Julie Shayne, RN, CCDS, Intermountain Health Clinical Documentation Integrity Educator

Documenting diagnoses related to brain pathologies accurately supports the intensity of your service, severity of illness, risk of mortality, lengths of stay and risk adjustment metrics.

Brain pathology diagnoses:

• Cerebral edema/Vasogenic edema

• Brain compression

• Brain herniation

• Hemorrhagic conversion of an ischemic stroke

• Brain injuries (i.e., SDH, SAH, epidural hemorrhages)

  • Identify the cause and acuity: traumatic vs. non-traumatic, SDH>acute vs. chronic, or acute on chronic

Key documentation concepts to apply:

• Coders cannot code from radiology reports. The clinician must interpret the clinical significance of these findings and document the diagnoses and treatment plan.

• Descriptions such as “some edema and midline shift noted on MRI” cannot be coded to cerebral edema and/or brain compression. The clinician must document a specific diagnosis of cerebral edema and/or brain compression, with the treatment monitoring, neuro status, etc.

Surgical case (embolization of MMA of SDH): 8-day LOS, impact without and with brain compression

Remember, your CDI team is here to help and serve as a resource for your documentation needs to ensure an accurate clinical picture of the patient is reflected. Please reach out to me with any questions.