Tip Sheets & Samples

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...

The attached PDF document include helpful reminders for physicians regarding documentation integrity and consistency regarding the discharge summary. Created by Paul Evans, RHIA, CCS, CCS-P, CCDS, this document can be adapted and posted in physician documentation areas.

Attached are four ICD-10 training games developed for JustCoding.com  Platinum subscribers and donated to ACDIS for its members. It includes a circulatory and musculoskeletal system word search, and a root operations crossword and root operations...

The attached PDF document contains documentation 26 documentation tip cards covering everything from CDI basics to physician evaluation and management (E/M) documentation requirements. Provided by Robert S. Hodges, BSN, MSN, RN, CCDS, the cards can be printed and folded together to create a...

This document provides documentation and coding advice for toxic metabolic encephalopathy. It was provided by Don Butler and comes from an HCPro e-newsletter, "HIM Connection." 

The attached Hospitalist Inpatient Progress Note will help hospitalists document patient assessment and the care plan. It was submitted by Kathy Shumpert, RN, Howard Regional Health System.

This is a sample of flashcards related to ICD-10-PCS and obstetrics from HCPro’s comprehensive ICD-10 Training Toolkit. The complete set of 24...

Courtesy of Ina Corley, clinical documentation specialist for Tulane Medical Center, this device associated infection documentation flowchart provides tips for accurate and consistent documentation.

This sample was reviewed and approved by the ACDIS Resource Library Committee in 2023. The committee noted that, should you use this resource, the CKD stages require more specification; in particular, this resource ought to be updated to include criteria for CKD 3A ad 3B. Jeanie Bellamy Director...

This sample was reviewed and approved by the ACDIS Resource Library Committee in 2023. Physicians won't forget to link the underlying cause of the infection after they've seen this educational poster created by Jeanie Bellamy Director Documentation Improvement & RAC Coordinator at Skyline...