Common errors in Diagnosis Documentation
Common errors in documentation • Incomplete PER-PD 301 (No diagnosis, No co-morbidities) • Multiple diagnoses in a row • Incorrect placement • Repeated diagnosis • Procedures as diagnosis • Illegible handwriting • Abbreviation / Acronyms • Unrecognized symbols # I D
Take home messages Please make sure : ✓ Main diagnosis and other diagnosis are documented ✓ Co-morbidities / underlying diseases are documented ✓ Procedures / operations are documented ✓All procedures executed by other allied health personnel are documented ✓PER-PD 301 is signed and stamped by discharging doctor (HO) and verified by MO/Specialist
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Thank You and Good Luck, comrades ! “It is not going to be easy, but it is going to be worth it..”