When AHIMA released its “Managing an Effective Query Process” brief in September 2008, it raised a number of concerns among them the responsibility of a CDI program to draft consistent policies and procedures for conducting physician queries. In...Read More »
Good communication is a key attribute of a successful clinical documentation improvement specialist (CDIS). The CDIS must be able to function in a variety of different settings. These include the CDIS office, the patient care unit, and presenting at rounds....Read More »
Q: We have a new CDI program with a huge learning curve. I am an RN in a CDI position. There are many things to ask, but the present issue is the re-querying done by the coders, which results in a large number of charts being held up. Has this been a familiar problem...Read More »
Q: We have been educated by our coding staff not to use the residents’ notes except as a guideline. They have said that they can only code the record from the actual attending documentation. We try to get physicians to co-sign the resident notes, and sometimes they do and sometimes they...Read More »
Does it sometimes seem like wound and pressure ulcer documentation is a movable feast? I’ve spent a lot of time scrutinizing wound documentation lately in anticipation of the new pressure ulcer codes being implemented October 1st and sometimes I...Read More »
Preface to the following: You won’t find a stauncher advocate for ethical behavior in the documentation compliance profession than me. I firmly believe that documentation compliance is all about quality, specificity, and the behaviors and...Read More »
