10 Documentation Tips Every Hospitalist Should Know
Hospitalists spend an average of 2 hours per day on documentation. That equals roughly 40% of your workday in the EHR instead of at the bedside. Documentation directly impacts billing revenue, legal protection, and care quality when patients transfer to the next provider.
Good documentation is not about writing more. It is about writing smarter.
This post covers 10 practical tips to help you document more efficiently while improving billing accuracy and medicolegal protection. These strategies come from practicing hospitalists.
Tip 1: Use Specific Problem List Titles
Problem list titles directly impact billing. Vague problem names lead to lower reimbursement and require clarification queries from coders.
| Generic (Avoid) | Optimized (Use This) |
|---|---|
| Heart Failure | Acute on Chronic Systolic Heart Failure Exacerbation (HFrEF, EF 30%) |
| Pneumonia | Community-Acquired Pneumonia, Right Lower Lobe |
| Kidney Injury | Acute Kidney Injury Stage 2, Prerenal Etiology |
| Anemia | Acute Blood Loss Anemia Secondary to GI Hemorrhage |
| Diabetes | Type 2 Diabetes Mellitus with Chronic Kidney Disease Stage 3b |
The optimized versions capture severity, chronicity, laterality, and etiology. All factors influence ICD-10 code selection and risk adjustment.
Pro tip: Include the ejection fraction in heart failure titles. “EF 30%” is worth documenting every time.
Tip 2: Document the “Why”
Every test ordered and medication prescribed should have documented clinical reasoning. This serves three purposes:
- Supports medical necessity for billing
- Protects you legally if decisions are questioned
- Helps the next provider understand your thought process
Instead of:
“Will order CT chest”
Write:
“Given persistent hypoxia despite diuresis and new left-sided pleuritic chest pain in patient with malignancy, will order CT chest with PE protocol to evaluate for pulmonary embolism vs malignant effusion”
The extra 20 seconds of documentation saves hours of explaining your reasoning later.
Tip 3: Be Specific with Numbers
Vague descriptors like “elevated,” “improved,” or “stable” require the reader to hunt through the chart for context. Specific numbers tell the complete story.
| Vague | Specific |
|---|---|
| JVP elevated | JVP 12 cm H2O |
| Weight down | Weight 94.2 kg (down 4.8 kg from admission) |
| Creatinine improving | Creatinine 1.6 (down from peak 2.4) |
| Tachycardic | HR 112, down from 130s on admission |
| Low-grade fever | Tmax 38.1C |
Numbers also allow trend tracking. When you document “Cr 1.6,” anyone can see where that fits in the trajectory. When you document “improving,” they have to check the labs themselves.
Tip 4: Use a Consistent Template
A standardized note structure reduces cognitive load and ensures you don’t miss elements. Your brain should focus on what to document, not how to organize each note.
Benefits of consistent templates:
- Faster documentation: Muscle memory takes over
- Fewer omissions: Every section prompts for required information
- Easier review: Colleagues know where to find what they need
- Better billing capture: Structured sections ensure you document billable elements
Check out our templates page for hospitalist-specific note structures designed for efficiency and compliance.
Tip 5: Document Trends, Not Only Current Values
A single data point tells you where the patient is. A trend tells you where they’re going.
Instead of:
“Weight 92 kg. Creatinine 1.4.”
Write:
“Weight 92 kg, down 5.2 kg from admission weight of 97.2 kg. Creatinine 1.4, stable from yesterday (improved from admission 1.9). Achieving approximately 1 kg/day negative fluid balance with current diuretic regimen.”
Trend documentation demonstrates:
- Response (or lack of response) to therapy
- Clinical trajectory
- Your ongoing reassessment
This is especially important for conditions like heart failure exacerbations, AKI, and infections where trajectory matters as much as absolute values.
Tip 6: State Your Goals
Documenting target values gives clarity to everyone involved in patient care: nurses, consultants, night cross-cover, and yourself tomorrow when you’ve forgotten the details.
Examples of goal documentation:
- “Goal weight 88 kg (dry weight per outpatient cardiologist)”
- “Target INR 2.5-3.5 for mechanical mitral valve”
- “Aiming for negative 1-1.5 L fluid balance daily”
- “BP goal per individualized assessment (commonly less than 130/80 if safely attainable in diabetes per AHA/ACC 2017, but verify patient-specific factors and current guidelines)”
- “Target glucose 140-180 per hospital protocol”
When goals are explicit, it’s obvious whether the patient is on track or needs adjustment.
Tip 7: Include Time-Based Elements
Time context helps anyone reading your note understand the clinical picture without calculating dates.
Include:
- Hospital day number: “Hospital day 4 of CHF exacerbation”
- Duration of symptoms: “6 days of productive cough prior to admission”
- Duration of therapy: “Now day 3 of vancomycin/piperacillin-tazobactam”
- Timeline of key events: “Intubated HD2, extubated HD5, transferred to floor HD7”
This is especially valuable during handoffs and when consultants review your notes.
Tip 8: Address Each Problem Daily
Every active problem deserves mention in every daily note, even if unchanged. The phrase “stable, continue current management” is acceptable and far better than silence.
Why this matters:
- Demonstrates ongoing assessment: You evaluated the problem and made a clinical decision
- Prevents problems from “disappearing”: A problem not mentioned might be assumed resolved
- Supports billing: Active problems contribute to complexity and risk adjustment
- Protects you legally: Shows you did not overlook anything
A problem list with 8 items and an A/P that addresses 5 creates ambiguity. Did you forget the other 3, or are they resolved?
Tip 9: Document Patient Communication
Conversations with patients and families about prognosis, goals of care, and treatment decisions are high-value documentation frequently omitted.
Document:
- What was discussed: “Discussed poor prognosis of stage IV lung cancer with patient and wife”
- Patient’s understanding: “Patient verbalized understanding of diagnosis and asked appropriate questions”
- Decisions made: “Patient wishes to pursue comfort-focused care, declining further chemotherapy”
- Who was present: “Family meeting with patient, spouse, daughter, palliative care team, and primary team”
These conversations take significant time and emotional energy. Document them thoroughly. They are clinically important and support billing for time-based E/M codes.
Tip 10: Use Evidence-Based Citations When Relevant
For key clinical decisions, referencing the evidence adds credibility and demonstrates thoughtful practice.
Examples:
- “Starting sacubitril-valsartan given survival benefit in PARADIGM-HF trial for HFrEF with EF ≤40%”
- “Implementing hour-1 sepsis bundle with early antibiotics and fluid resuscitation per Surviving Sepsis Campaign 2021”
- “Continuing P2Y12 inhibitor monotherapy (after completing short-course DAPT) post-PCI per TWILIGHT trial in selected patients with high bleeding risk (verify eligibility and local protocols)”
You don’t need citations for every decision. But for non-obvious choices or when your management might be questioned, a brief reference strengthens your documentation.
Bringing It All Together
Good documentation improves with deliberate practice. You don’t need to implement all 10 tips tomorrow. Pick 2-3 that resonate and focus on those for a few weeks until they become automatic.
Summary:
- Specific problem titles improve billing capture
- Document the “why” for legal protection and clarity
- Use numbers instead of vague descriptors
- Consistent templates reduce cognitive load
- Trend documentation shows clinical trajectory
- Explicit goals guide the care team
- Time-based elements provide context
- Address every problem daily
- Document conversations with patients and families
- Cite evidence for key decisions
CasePanel builds these principles into our documentation tools. Our templates structure your notes for optimal billing capture, and the AI assistant generates specific, evidence-based assessments and plans in seconds.
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