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Handbook: UNC Healthcare

Tiffany H. Estes, RHIA, CCDS, CDI Supervisor for UNC Healthcare in Chapel Hill, N.C., donated this 60-plus page UNC Healthcare Clinical Documentation: Handbook for Physicians and other Licensed Healthcare Providers, which took her team more than 100 hours to create.

It explores the importance of CDI programs, outlines physician query basics and general documentation guidelines, and discusses top documentation concerns by diagnosis including encephalopathy, pneumonia, sepsis, anemia, and dementia, among other important items.
 

 

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