Q: A patient came to the emergency department with shortness of breath (SOB). The admitting diagnosis was possible acute coronary syndrome (ACS) due to SOB and elevated troponin levels. The ACS was ruled out. Elevated troponin levels were assumed to be due to chronic renal failure (CRF),...Read More »
Do you sometimes feel like you and the physicians at your hospital aren’t communicating as well as you could be? Even the best of us can feel like a buzzing fly, annoying physicians when trying to gather needed information in the middle of a busy day, says James Haering, DO, SFHM,...Read More »
One of the biggest documentation problem areas pertaining to patient safety indicators (PSI), particularly related to PSI 90, stems from accidental puncture and laceration (APL), says Katy Good, RN, BSN, CCDS, CCS, clinical documentation program coordinator at Flagstaff Medical Center in Arizona...Read More »
Sure, CDI practices might lead a hospital to the proverbial pot o’ gold hidden in the medical record, but in the early days of the profession, finding someone with the experience necessary to perform the role was akin to capturing a leprechaun. While there are a host of experienced CDI...Read More »
CDI specialists and their coder counterparts may pose hundreds-even thousands-of queries throughout their careers. One thing remains constant; there's always room for improvement. How can CDI staff and coders write more effective queries and essentially get more bang for their buck? A number of...Read More »
We believe that the CDI profession may be well poised as the architects of the sturdy infrastructure needed in this new landscape. After all, the profession was built on change.Read More »
Reconciliation is the process of reviewing medical record documentation and comparing this information to the coding summary: principal diagnosis, secondary diagnoses, present on admission indicators, procedure(s), and discharge disposition.Read More »