Cheryl Ericson, MS, RN, CCDS, CDI-P, CDI education director at ezDI, donated this sample query to demonstrate how CDI specialists can use their queries as a method of clinical validation--to ensure the diagnosis documented in the medical record includes the necessary clinical indicators to...
Use this example definition of postoperative respiratory failure as adapted by New York University Langone Medical Center's Mary McGrady, MSN, RN, CCDS and Murali K. Nagarajan, CCS, MB, BS following their webinar presentation...
These sample ICD-10 focused queries were donated by Cheryl Ericson, MS, RN, CCDS, CDIP, CDI Education Director for HCPro in Danvers, Mass., and ACDIS Advisory Board member Mark LeBlanc, RN, MBA, CCDS, Clinical Documentation Manager, at Hennepin (Mo.) County Medical Center, who spoke during the...
These sample queries were donated by Cheryl Ericson, MS, RN, CCDS, CDIP, CDI Education Director for HCPro in Danvers, Mass., and ACDIS Advisory Board member Mark LeBlanc, RN, MBA, CCDS, Clinical Documentation Manager, at Hennepin (Mo.) County Medical Center, who spoke during the June 10 webinar...
Use this query when the physician admits a patient with a history of alcoholism but provides no diagnosis. Provided by Cheryl Ericson, MS, RN, CCDS, CDIP,...
The attached Word document represents one example of a possible request for diagnostic clarification/confirmation of diagnosis donated by Paul Evans, RHIA, CCS, CCS-P, CCDS. This item was reviewed by the Resource Library Committee in 2023 with the recommendation that a section be added to allow...
The sample ICD-10 queries included in the attached document address common coding and documentation themes associated with the ICD-10 code set. Adapted from ...
Cynthia Prayzner at Southcoast Health System in New Bedford, Mass., offers this sample altered mental status query form which asks physicians to identify the chronicity of the diagnosis providing additional specificity not on the query form but in the medical record's progress note.
This sample was reviewed and approved by the ACDIS Resource Library Committee in 2023. The committee noted that if you use this resource, it requires a space to index clinical indicators, and the resource must be rid of all bold and underlined phrases, as these are considered leading queries...
