Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, C-DAM, CDI manager at Washington Adventist Hospital worked with his medical and quality staff to create this audit tool to use when reviewing a record and providing feedback to physicians on the quality of their documentation.

The attached Word document contains a proposal for mandatory physician education regarding facility CDI practices. Created by Rebecca "Ali" Williams, RN, BSN, CCDS, this document can be adapted and brought forward to your facility's medical staff director or your program director to foster the...

This is a mortality review spreadsheet that lists age, unit, DRG, SOI/ROM scores, Pdx, mcc/cc’s, secondary dx’s, DNR/Palliative status, and whether the case was reviewed by a CDS. In this example, patient identifier information has been deleted. The spreadsheet was submitted by Vicki Davis of...

This policy outlines processes for physician queries. It is provided by Donald A. Butler, Manager of Clinical Documentation at Vidant Medical Center in Greenville NC.

This policy establishes guidelines for inpatient physician queries. It is provided by Donald A. Butler, Manager of Clinical Documentation at Vidant Medical Center in Greenville NC.

This policy establishes the procedure for scanning CDI worksheets. It is provided by Donald A. Butler, Manager of Clinical Documentation at Vidant Medical Center in Greenville NC.

This policy establishes guideline for the CDI program practice and process. It is provided by Donald A. Butler, Manager of Clinical Documentation at Vidant Medical Center in Greenville NC.

This document is a position statement for clinical documentation improvement. It is provided by Donald A. Butler, Manager of Clinical Documentation at Vidant Medical Center in Greenville NC.

This is a policy for clinical documentation improvement compliance practices. It is provided by Donald A. Butler, Manager of Clinical Documentation at Vidant Medical Center in Greenville NC.

Here is an auditing and monitoring presentation courtesy of Donald A. Butler, RN, BSN, Manager of Clinical Documentation at Vidant Medical Center. The 43-page PowerPoint also incldues information about good query processes.

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