Imagine this scenario: An 82-year-old female presents with right-sided weakness and aphasia. Imaging reveals ischemia and admits her for a Cerebrovascular accident. You sit down to put in orders and write your note: “Left MCA CVA due to thrombosis...”
To avoid a query and comply with ICD-10, here is a quick review of the three required elements of ischemic CVA documentation:
Remember, you can document LIKELY or POSSIBLE. If any of the elements are unknown, document it as such. Correct documentation gives you the credit you deserve for your hard work and exceptional care you provide to our patients at Salem Health.