CDI Journal - Volume 5, Issue 1

Ask ACDIS: Query appropriately for fluid overload vs. CHF

January 1, 2011
Ask ACDIS, Physician Queries

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 »
CDI Blog - Volume 4, Issue 60

Guest Post: Santa’s not the only one watching to see if you’ve been bad or good

December 22, 2011
ACDIS Guidance, Physician Queries

by Sylvia Hoffman, RN

Singing: He sees you when you’re sleeping. He knows when you’re awake. He knows if you’ve been bad or good, so be good for goodness sake.

Remind you of anyone? No? Here’s a hint. It rhymes with knick-knack but these...Read More »
CDI Blog - Volume 4, Issue 39

Guest Post: Use radiology findings to support your physician queries

August 26, 2011
ACDIS Guidance, Physician Queries

by Lynne Spryszak, RN, CCDS, CPC

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 »
CDI Blog - Volume 4, Issue 38

Guest Post: A change in perspective may help build better physician relationships

August 22, 2011
ACDIS Guidance, Physician Queries

by Linda Renee Brown, RN, MA, CCDS, CCS, CDIP

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 »
CDI Blog - Volume 4, Issue 31

Guidance and tact key to compliant, effective physician queries

July 1, 2011
Physician Queries

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 »
CDI Blog - Volume 4, Issue 29

Guest Post: Physician collaboration: Identifying the keys to success?

June 27, 2011
ACDIS Guidance, Physician Queries

by Donald A. Butler

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 »
CDI Blog - Volume 4, Issue 27

Guest Post: Query questions: When should you not query?

June 9, 2011
ACDIS Guidance, Physician Queries

by Robert S. Gold, MD

I recently attended the annual meeting of the ACDIS in Orlando where I heard a variety of perspectives during many informative presentations.

A common thread in many discussions was how to query physicians using information in the medical record and...Read More »
CDI Blog - Volume 4, Issue 23

Q&A: Keeping electronic query copies

May 26, 2011
Ask ACDIS, Physician Queries

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 »

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