ICD-10 strategies: Document consistently, with the right amount of detail

  • Jeff Goldstein, MD, MS FACHE
  • 05/06/2015

ICD-10 is the largest mandate in U.S. healthcare history, and it will require diligent, comprehensive actions to be fully prepared for the transition. This is the fourth post in a four-part series that explores successful strategies in key areas of ICD-10 readiness: general approach, governance, education and standardization of documentation. “The pen is mightier than the sword,” is a famous line from Edward Bulwer-Lytton’s 1839 play, The Conspiracy. Fast-forward nearly two centuries, we substitute the keyboard for the pen, and the idea is nonetheless the same; documentation is the quintessential element that translates one’s thoughts and actions into a durable record of key events in health care. Unfortunately, the lack of uniform documentation is the Achilles’ heel for ICD-10 readiness across the entire industry. Concise, thorough and comprehensive documentation is not only essential, but it is the required basis for […]