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Health care is changing from quantity to quality of care provided to the patients. It is difficult to accurately define quality in healthcare settings. Among other things, quality is also linked to severity of patient illness. But this severity must be clearly reflected in physician documentation in order for it to be accurate. Current coding system may not accurately pick up the severity due to poor matching of documentation with many specific conditions.

Although electronic medical record has helped in this matter but provider documentation still need to be present to link coding and severity. A severely sick patient may not look sick after coding unless appropriately documented. The choice of words used is extremely important in order to accurately capture this severity of illness.

This book provides specific information about the use of those words. A good example would be 'leaking abdominal aneurysm'. A statement used by some surgeons for acutely ruptured abdominal aortic aneurysm. Leaking abdominal aneurysm may be completely understood by his/her colleagues and other medical staff but may not be understood by the coding system which may capture this as 'stable abdominal aortic aneurysm'. The severity of illness and mortality for the patient with spontaneous ruptured aortic aneurysm is extremely high compared to a stable chronic abdominal aortic aneurysm. Bad outcome for this patient will be looked at differently in terms of quality of care provided by the surgeon and the hospital as a whole based upon appropriate documentation.

I hope the reader would be able to use the appropriate words to clarify the medical conditions they are treating in order to receive relevant credit for the quality of work done. This will also allow the hospitals to accurately assign DRGs for the treatment provided.

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