Of the 187 physicians who responded to a recent survey, only 25% were involved in evaluating or implementing new clinical documentation technologies at their organization. However, when asked how important they considered being involved, 70% said extremely important and 27% said very important...Read More »
Careful use of terminology may help alleviate miscommunication in situations of potential tragedy. Following the recent death of 33-year-old Marlise Muñoz, who was declared brain dead at a Fort Worth hospital, facilities may want to take the opportunity to review their internal guidelines for...Read More »
Q: We recently admitted a 52-year-old man who was waiting for a liver transplant. He has a history of hepatitis C, chronic back pain, and drug and alcohol abuse. He was found unresponsive at home in a pool of vomit. The toxicology screen on admission was positive for benzodiazepine,...Read More »
It's time to gather nominations for the CDI Professional of the Year, at be awarded at the seventh annual ACDIS Conference, May 7–9, 2014, in Las Vegas.
In addition to the CDI Professional of the Year, ACDIS will also award two members with the...Read More »
Contractors could use a little guidance from CMS to do a better job at reviewing medical records for electronic health record (EHR) problem areas. For example, clues within the progress notes, hand writing styles, and other attributes that help corroborate the authenticity of paper medical...Read More »
Of the nearly 450 respondents to a recent ACDIS website poll, 50% say they conduct pre-payment record reviews, with an additional 7% indicating their facility is considering implementing such reviews in 2014. Of that 50%, 35% of...Read More »
Q: We are struggling with how to query physicians regarding complications of procedures or surgeries. For example, a patient was readmitted for a bile leak two weeks after a cholecystectomy. Neither the attending nor the GI consultant ever stated that this was a complication. Can you...Read More »
