This tip sheet regarding post-operative surgical complications was donated Audrey G. Howard, RHIA, AHIMA-Approved ICD-10-CM/PCS Trainer, and Cheryl Manchenton, RN, BSN, 3M Consulting, adapted from the 2012 HCPro Inc., audio conference Inpatient Postoperative Complications: Resolve Your...

ACDIS Advisory Board member Timothy N. Brundage, MD, created these sample CDI sample newsletters which he shares with physicians at his facility. They include:

  • Anemia
  • ATN
  • Bacteremia
  • Encephalopathy
  • Functional quadriplegia
  • GI bleed
  • ...

The attached zip file contains a physician documentation tip sheet, a CDI specialist worksheet, a tracking spreadsheet, and sample procedure for obtaining documentation regarding patient mortality, submitted by Vicki Davis, RN, CDI specialist at Alamance Regional Medical Center, Burlington, N.C...

The attached Word document includes clinical indicators, definitions, and coding tips to help train CDI professionals on respiratory failure documentation improvement opportunities. Created by Paul Evans, RHIA, CCS, CCS-P, CCDS, this document can be adapted and added to ongoing CDI training...

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.

The attached PowerPoint document offers elemental physician documentation improvement tips regarding heart failure. Created by Linda Renee Brown, RN, MA, CCDS, CDIP, CCS, it can be amended and used during physician or CDI and coding staff education sessions.

The attached Word document from the Department of Health & Human Services Agency for Healthcare Research and Quality (AHRQ) includes a sample query form and outlines specific strategies for successful documentation and coding. Submitted by Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS...

The attached Word document is a sample tip card for physicians regarding general documentation requirements regardingt topics such as anemia, respiratory failure, altered mental status, chemotherapy, among other common CDI concerns. Created by Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP, HIT Pro...

The attached Word document is a sample tip card for physicians regarding documentation requirements to capture medical necessity for joint replacement. Created by Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP, HIT Pro-CP, it can be printed on card stock, folded, and trimmed as indicated and given...

The attached Word document is a sample tip card for physicians regarding heart failure core measure diagnosis codes. Created by Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP, HIT Pro-CP, it can be printed on card stock, folded, and trimmed as indicated and handed to physicians, nurses, quality or...

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