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Tip Card: History and physical documentation
The attached Word document donated by Mary Solomon, BSN, RN, CCM, CCDS, CDI specialist at Tahoe Pacific Hospitals in Reno, Nev., offers improvement tips for physicians history and physical documentation. It can be used as a handout following an educational session, posted in the physician lounge, or delivered individually to physicians as needed.
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ACDIS is the nation's only association dedicated to the clinical documentation improvement profession. Whether you're a veteran CDI specialist or new to the position, or a physician advisor or HIM/coding professional, you'll want to take advantage of all the benefits of ACDIS membership including a career center, CDI Journal, CDI Forum, sample forms and tools, and much more.
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