My physicians use the term “bacteremia” frequently and are treating it. The patient may be febrile and receiving antibiotics, but they cannot...Read More »
We’re having a lot of discussions lately on whether we should query for pressure injuries when they’re only documented by nursing. Our wound care...Read More »
CDI leaders’ responsibilities are varied and far reaching. Rather than going the journey alone, leaders can gain valuable insight by connecting with peers outside their organizations to collaborate, trade advice, and share challenges and successes.
I recently listened to a webinar where treatment was emphasized especially for diagnoses such as sepsis, acute respiratory failure, and severe...Read More »
Our providers tend to use the term “RDS” in their documentation to describe all “respiratory distress,” “respiratory distress syndrome of newborn...Read More »
According to our software vendor, you can only code liver lacerations as minor, moderate, or major. According to all the educational materials I...Read More »
What are the requirements when it comes to a physician advisor asking for diagnoses to be added to the medical record? Based on the ACDIS/AHIMA “...Read More »
Our query process currently creates a physician progress note when a query is answered which becomes part of the permanent medical record. We do...Read More »
I believe there was a Coding Clinic several years ago where the diagnosis of “mental incompetence” was changed to “intellectual disability,” but I...Read More »
How can real-time chat function in an electronic health record (EHR) be used? Are CDI specialists and physicians receptive to a real-time chat?Read More »
