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During a post-audit conference I was told by a physician that when a diagnosis of stroke is identified and documented, that others (auditors) should appreciate what that means. While auditors are clinicians, a diagnosis does not describe the patient's presentation on pre-admission or admission. To establish why a patient requires intensive inpatient services, documentation must include all the relevant conditions associated with the stroke (type of hemiplegia/paresis, dysphagia, aphasia, visual disturbances, impulsivity, etc) and other comorbidities that complicate the patient's current condition (cardiac, respiratory, wound management, pain). When a pre-admission screener and coder work together to capture all relevant conditions, it provides a starting point for other facility clinicians to build upon as evaluations progress. Efficiency, in this case is derived from a team approach to documenting and coding what is observed regarding the patient's disease, disorder or injury and the resulting disabilities. 

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