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...
The attached Word document reviews documentation and coding needs for complications and establishes policies and procedures for coders and CDI professionals to follow. Created by Paul Evans, RHIA, CCS, CCS-P, CCDS, the document provides complication definitations, explains when queries should be...
The attached PowerPoint document offers a sample education session for physicians regarding documentation and coding needs for complications. Created by Paul Evans, RHIA, CCS, CCS-P, CCDS, the presentation provides complication definitations and walks physicians through related CDI and coding...
