December Douglas, RN, CCDS, is a clinical documentation integrity specialist at Memorial Hermann Hospital, Texas Medical Center, in Houston, Texas.Read More »
Follow these steps to keep your verbal interactions brief and to respect not only the physician’s limited time but also his or her knowledge of the patient’s condition.Read More »
Q: What do you suggest the providers write to describe medication/substance overdose? In my experience, physicians don’t write “poisoning” in these cases. Read More »
Darla Martin, RHIA, CCS, CCDS, is a clinical program manager at Iodine Software. She is a member of the North Carolina and South Carolina ACDIS local chapters, a member of AHIMA and PAHIMA, and is a volunteer member of the ACDIS Forms & Tools Library Committee.Read More »
Jera Van Damme, BSN, RN, CCDS, is a senior clinical documentation educator at Essentia Health in Duluth, Minnesota, a member of the Minnesota ACDIS Chapter, and a member of the ACDIS Forms & Tools Library Committee.Read More »
By Laurie L. Prescott, MSN, RN, CCDS, CDIP, CRC, and Sharme Brodie, RN, CCDS
What do physicians need to learn about CDI? Just about everything—up to a point. If you are joining a new CDI program, physicians likely need to learn what a CDI program is, how it functions, and how it...Read More »
Q:As far as coding guidelines go, the role of the attending physician’s documentation in the medical record and discharge summary are pivotal for correct code assignment. However, our system uses hospitalists which means the...Read More »