title: Language is key in clinical documentation.
abstract: Medical language and coding language are not the same, which means that physicians often write what they learned in medical school to describe a patient's condition: if it doesn't contain the proper language, the coders can't accurately code the chart. Educate physicians to use appropriate language to reflect the condition of the patient. Look for hints in documentation by other clinicians that the physician documentation might not be accurate. Ensure that documentation is complete to indicate major complication/comorbidity rates (CCs or MCCs).
mesh_terms: D019090:Case Management; D059019:Clinical Coding / Q000592:standards*; D006801:Humans; D007297:Inpatients; D009626:Terminology as Topic; D014481:United States