This is a classic documentation opportunity to clarify “volume/fluid overload,” says Lynne Spryszak, RN, CPC-A, CCDS, CDI education director for HCPro, Inc., in Danvers, MA. “If the physician hasn’t documented acute CHF, I would hesitate to ask for this condition based on this mild BNP elevation...Read More »
A patient’s medical record contains a wealth of information about his or her hospital encounter, including diagnoses, treatments, operative reports, and ancillary notes. Unfortunately, much of the detailed information found in a patient record is...Read More »
I’m an old (and I do mean OLD) ICU nurse. As a working nurse, my relationships with physicians usually centered on getting them to listen to my assessments: Yes, you need to get out of bed and come see this patient who has stopped...Read More »
When it comes to querying physicians, CDI specialists need to first recognize when it’s appropriate to query. The next step? Using tact in the wording of the query. This will help ensure compliance and elicit appropriate clarification from the physician. Although doing so does not have to be a...Read More »
Over and over again in CDI Talk, at the ACDIS conference, local chapters, anywhere two CDI professionals have an opportunity to interact, it seems, some very common topics arise. One of the most common it seems is how to gain cooperation and collaboration of...Read More »
Q:Our program does not typically include query information as part of the medical record. If the physician responds to a faxed query, we scan the fax into our electronic record. However, we resolve most queries in person or through a secure messaging system in our EMR (...Read More »
