Tip: Tie in national health observances to your documentation improvement efforts
CDI Strategies, May 14, 2008
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CDI specialists might want to consider tying their documentation education into the current month’s national health observance, suggested Gloryanne Bryant, RHIA, CCS, senior director of corporate coding/HIM compliance for Catholic Healthcare West in San Francisco, CA, at the first Association of Clinical Documentation Improvement Specialists (ACDIS) conference in Las Vegas, held May 8-9.
For example, May is American Stroke Month (click here for a complete listing of health observances by month ). Consider the following tips to help physicians improve their stroke documentation:
1. When formulating a query, ask the physician to clarify a “CVA/stroke” diagnosis as follows:
Additional documentation is necessary to identify the specific type of CVA/stroke, and the site, if known.
- Type (e.g., hemorrhage, embolic, thrombolic, ischemic, other, unknown)
and - Site (e.g., cerebral, basilar, carotid, vertebral, other, unknown)
2. Review the documentation for information about the patient’s level of consciousness. If the patient is in a coma or has been in a coma since they were admitted or in the ED/ER, this should be coded to reflect severity/acuity. If there are clinical indications of a coma, you should query the physician for clarification and obtain supporting documentation if appropriate.
3. Educate physicians that they should also document any clinical residuals or deficits from the CVA/stroke.
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