by Jill Dressler, RN, BSN, CCDS and Sandy Frey, RHIT, CCS
CDI has many parts: documentation analysis, provider engagement, program infrastructure, and performance monitoring. One way to monitor staff’s effectiveness is to audit their query practices. This ensures CDI staff capture...Read More »
Q: Our physician advisors are requesting the question and options be listed before the clinical indicators and treatment in the query. I could not locate any direction regarding this format in the current ACDIS/AHIMA physician query practice...Read More »
by Tracy Boldt, RN, BSN, CCDS, CDIP, and Ellen Jantzer, RN, MSN, CCDS, CCS, CRC
The rules of compliant query practice do not change based on the setting. We must consider query construction and wording of provider communication with the same eye for compliance as we have...Read More »
By Cheryl Ericson, RN, MS, CCDS, CDIP, and Cathy Farraher, RN, MBA, CCM, CCDS
Whenever CDI staff is uncomfortable sending a clinical validation query, the physician advisor should be consulted both prior to sending it, as well as prior to following up on the response if necessary...Read More »
The question often surfaces regarding what to do with CDI queries once they have been issued. My best advice is keep them. Most facilities do not consider concurrent queries part of the permanent medical record because physicians respond...Read More »
By Cheryl Ericson, RN, MS, CCDS, CDIP, and Cathy Farraher, RN, MBA, CCM, CCDS
Without a team that is fully engaged, it is impossible to maintain a compliant organization in terms of documentation. As time passes and clinical teams become more accustomed to, and comfortable with,...Read More »
The first time I read “airway protection” documented in the medical record, I realized it would require a more in-depth record review and research because airway protection by itself is not a diagnosis. It does, however, imply potential or impending...Read More »
