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How to document an icschemic CVA correctly

25 Nov 2018

Avoid queries with tips from HIM

By: Lindsay Newcomer, RN, BSN, CDIS, clinical documentation specialist

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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:

  1. Laterality (left, right)
  2. Likely cause (embolism, stenosis, thrombosis, occlusion)
  3. Affected vessel (MCA, ACA, PCA, carotid, etc.)

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.