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 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 »
Hey, you CDS with new programs out there! How’s it going? Are you sailing along on the smooth seas of phenomenal MCC capture rates or are you stalled in the doldrums? Are you asking yourself the following question: “What do I do now that the...Read More »
While those of us at ACDIS are already working as CDIS there are nurses and coders out there who e-mail me and ask how to become a CDIS so I thought I’d write about what I look for when I’m hiring someone. FYI, folks, opinions ahead.Read More »
