This form requests additional information for a stated diagnosis. It is provided by Jill Lindsey, RN, BSN, of Phoenix Children's Hospital.

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

 

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This ICD-10 myocardial infarction query is courtesy of Fran Toleno, RHIT, CCS, CDI coordinator and coding reimbursement specialist in the HIM department at Winthrop University Hospital in Mineola, NY. It was published in the February 2012 issue of Medical Records Briefing.

This ICD-10 cerebral artery infarction progress note is courtesy of Fran Toleno, RHIT, CCS, CDI coordinator and coding reimbursement specialist in the HIM department at Winthrop University Hospital in Mineola, NY. It was published in the February 2012 issue of Medical Records Briefing...

The attached is a sample progress note regarding Congestive Heart Failure (CHF) courtesy of Rebecca "Ali" Williams, RN, BSN, CCDS, manager of Documentation Integrity at Spartanburg (SC) Regional Medical Center & Village Hospital. It is intended as a sample only and any diagnostic criteria...

Courtesy of Rebecca "Ali" Williams, RN, BSN, CCDS, manager of documentation integrity at Spartanburg (SC) Regional Medical Center and Village at Pelham Hospital via the ...

Signs or symptoms of an underlying condition should be coded only if the physician can not determine a definitive diagnosis. When the physician simply neglects or forgets to document the diagnosis, CDI staff can use this sample query template provided by Alesha Andrews, RHIT, CCS, and Adam...

The attached debridement documentation form was provided by Susan A. Klein, BSN, RN, C-CDI, director of clinical documentation management at Saint Peter's University Hospital in Monroe Township, NJ.  It is intended as a sample only and any diagnostic criteria should meet the approval of your...

When the physician documents acute renal insufficiency or renal insufficiency in the medical record additional information may be required to more accurately reflect proper severity/acuity. Janice Davis, RN, clinical documentation analyst at High Point (NC) Regional Health...

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