The document discusses ICD-10 documentation requirements for palliative care. With ICD-10, palliative care documentation requires a more comprehensive and specific level of detail. This includes specifying disease type and status, etiology, manifestations, complications, and other relevant medical information. Electronic health records can help by providing templates, access to past patient visits, and integrated test result ordering, but errors from copy-pasting and limitations of narratives remain challenges. EHR transcription is presented as an effective way to address these issues.

1. ICD-10 DOCUMENTATION FOR
PALLIATIVE CARE
With ICD-10, a more comprehensive and specific documentation is required
for palliative care.
Medical Transcription Services

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Palliative care improves the quality of life of patients with life-threatening problems by
ensuring early identification and providing impeccable assessment and treatment.
Complete and accurate clinical documentation is essential to enhance care provision,
communication and teamwork in a palliative care unit. As the ICD-10 implementation
date is fast approaching, it is very important to make the necessary changes to your
documentation to accommodate new codes and definitions as quickly as possible. This
will not only increase your reimbursement, but also improve the quality of palliative care.
The ICD-10 documentation for palliative care requires higher level of specificity and
more comprehensiveness. The key impacts to ICD-10 documentation are as follows:
 Disease or disorder site
 Acuity and/or encounter status of treatment
 Etiology, causative agent, or disease type and injury/poisoning cause, intent,
activity at the time of the event and place event occurred
 Manifestation
 Complications or adverse events
 Supporting information such as lab values or socioeconomic key impacts to ICD-
10 documentation
Let’s take a detailed look into the ICD-10 documentation for commonly found and
critical diagnoses in palliative care unit.
Leukemia
While documenting leukemia, you should specify the type (Acute lymphoblastic, Acute
Myeloid, Acute Myelomonocytic, Acute Promyelocytic or Acute Myeloblastic). You
should also identify the disease status as being ‘In remission’, ‘Not having achieved
remission’ or ‘In relapse’.

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Malignant Neoplasm
The documentation of malignant neoplasm must include the following:
 Identify the site (pelvic bones, brain stem or parietal lobe)
 State the morphology as malignant or primary/secondary
 Specify the stage and any metastatic site
 Indicate any related exposure to smoke (second hand smoke)
 Details when the patient is presented for treatment related to neoplasm (for
example, chemotherapy)
How EHR Enhances Your ICD-10 Documentation
Electronic health record systems or EHRs have the following the qualities that facilitate
ICD-10 transition.
 Templates – Documentation templates within the EHR system help physicians to
incorporate all important details about the patient for proper ICD-10
documentation in a clear, organized and structured manner. The templates can
also be used to remind physicians to ask their patients specific questions for
comprehensive documentation.
 Ability to Access Previous Visits – The ability to access the patient’s previous
visits can supply more information to the physicians such as pertinent medical
history and test results to perform the correct diagnosis.
 Integrated Order System for Ancillary Services – Most EHR systems are
capable of integrating orders for lab, radiology and pharmacy services into the
patient’s current visit and this will provide a complete record of that patient’s
encounter for that date.

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These facilities will help physicians to document the details for each patient encounter
with high precision to incorporate laterality, co-morbidity, anatomic location and other
specific details. However, errors from frequent copy pasting and limitations to narrative
description are the major challenges with regard to EHR documentation. EHR
transcription is an effective way to eliminate these drawbacks. In this approach, skilled
and experienced transcriptionists transcribe the physician’s dictations and the transcribed
data is populated into corresponding fields. This option is also useful to reduce the speech
recognition errors with speech-enabled EHRs.