#A PATIENT WITH AN ALTERED MENTAL STATUS IS HOW TO#“Most residents have never had any education on how to document from anyone other than their attending physicians. The greatest disconnect may be in that physicians are rarely, if ever, offered the opportunity to learn how to properly document or why it’s even important. The coder is extracting language to produce codes, and there is a great big disconnect between those worlds,” explains Timothy Brundage, MD, CCDS, medical director of The Brundage Group. “You read the in high-impact journals like the New England Journal of Medicine and the Annals of Internal Medicine,” says James Kennedy, MD, CCS, CDIP, CCDS, founder and president of CDIMD, a physician consulting firm.Īs a result, physicians who use the terminology that they were taught in medical school and that appears in esteemed industry journals have good reason to believe they are accurately documenting a patient’s mental state.īut many practitioners fail to realize that the language they deem commonplace does not always translate to an ICD-10 code. Indeed, physicians are using what they know to be a widely agreed-upon phrase when they note their patients’ altered mental status. “The problem is it was always a general descriptor and never provided any additional information about why they were having an altered mental status.” #A PATIENT WITH AN ALTERED MENTAL STATUS IS PROFESSIONAL#“It’s considered a much more professional way to describe someone who is flipped out,” says Victor Freeman, MD, MPP, an adjunct assistant professor in the HIM graduate department at the University of Maryland and national medical director for CDI for Nuance Communications. As a result, they’re recognizing the generic term doesn’t cut it.Īltered mental status is a phrase all medical students learn early in their education to describe patients who are in some way confused or exhibiting limited consciousness. Unfortunately, physicians are finding more occasion to document altered mental status due to the rise in Alzheimer’s disease as well as the opioid epidemic. When clinical documentation improvement (CDI) experts discover altered mental status is being used as a diagnosis within the chart, they know two things: The documenting physician is undervaluing the care he or she is delivering, and a little education is in order. However, use of the term becomes problematic when it makes its way from clinical conversation into clinical documentation. Generally speaking, the term is just fine when a physician is, well, generally speaking. Use of this generic term in clinical documentation often leads to misrepresentation of the care being provided.Īltered mental status is a phrase commonly uttered among clinicians to characterize a broad spectrum of behaviors and states of being that range from confusion to coma.
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