Clinical work is demanding. Patients need answers, decisions must be made quickly, and documentation often comes last even though it is the only lasting record of the care you provide. In that busy environment, even skilled and thoughtful clinicians can unintentionally leave out details that matter for patient safety, communication, and accurate coding.
Nine Documentation and Coding Pitfalls Every Clinician Should Avoid was written to make documentation clearer, easier, and more purposeful. This guide explains the pitfalls clinicians most often fall into, why they happen, and how to avoid them in a way that fits naturally into everyday practice.
Drawing from years of experience as a clinician, medical coder, and national educator, the author offers practical insight and tools that clinicians can use right away, including:
Clear explanations of documentation expectations
Real examples that show how to document chronic illness with exacerbation, prescription drug management, systemic symptoms, and undiagnosed new problems
Guidance on capturing comorbidities, independent historians, and tests that were considered but not ordered
Templates and phrases that help you show your reasoning, your risk assessment, and your plan
Case scenarios that reveal the difference between strong and weak medical decision making
This book is not about checking boxes. It is about telling the clinical story in a complete and meaningful way. It is about making your thought process visible. It is about improving clarity, reducing avoidable risk, and ensuring your documentation reflects the real work you do.
Whether you are a physician, physician assistant, or nurse practitioner, this guide will help you document with confidence and consistency. It is practical, friendly, and designed to make your next note and every note after that stronger and easier.
A helpful and reliable companion for any clinician who wants to improve documentation, support accurate coding, and strengthen patient care.