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ACDIS - Forms and Tools content records with attached documents


Device associated infection documentation flowchart

Courtesy of Ina Corley, clinical documentation specialist for Tulane Medical Center, this device associated infection documentation flowchart provides tips for accurate and consistent documentation.

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Poster: Heart Failure Acuity

The attached Word document offers quick documentation improvement tips for specifying the acuity and type of heart failure. Created by Cindy Ulrich, RN, MSN, this document can be printed out and hung in physician common areas or documentation rooms.

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Query Letter: Capturing Mortality Documentation

The attached Word document represents a sample query cover letter aimed at capturing additional documentation needed for appropriate severity of illness/risk of mortality for a patient who passed away while under care. Created by Christine Raad, the letter was intended to accompany additional query forms and to explain the reasoning behind the mortality queries.

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Unanswered query and query conflict escalation policy

The attached Unanswered query and query conflict escalation policy is a sample policy for handling unanswered physician queries and/or CDI/coding conflicts that require resolution. The policy is courtesy of Lynne Spryszak, RN, CCDS, CPC-A, CDI education director for HCPro, Inc.

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Pneumonia documentation decision tree

This attached pneumonia documentation decision tree, courtesy of Gina Spatafore of Waterbury Hospital, is designed to help physicians document pneumonia, unspecified to the highest degree of specificity.

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CDI presentation for nurse managers

This attached powerpoint presentation is to instruct nurse managers in the purpose and benefits of clinical documentation improvement. This presentation is courtesy Janice Davis, RN, BA, CCDS, clinical documentation analyst for High Point Regional Health System.

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2011 Conference: Physician Queries: An Effective and Compliant Method for Success

Attached is the powerpoint presentation Physician Queries: An Effective and Compliant Method for Success by Andrew Rothschild, MD, MS, MPH, FAAP, CCDS. ♦ Note that this includes the updated slides presented live at the conference.

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Physician report card

The attached physician report card, developed by the CDS team at St. Cloud Hospital in MN, is a tool to educate physicians about Severity of Illness and Risk of Mortality scores. These scores are used for statistical purposes to rank physicians and hospitals, and they also impact risk-adjusted outcomes such as the Mortality Index, complication rate and readmission rates.

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Coding guidelines for physicians

The CDS team at St. Cloud Hospital in Minnesota put together the attached coding guidelines for physicians. These can be used as a reference for the CDI department or as an educational handout for physicians.

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Query Process Flow Chart

This sample flow chart illustrates the physician query process from initial query submission through to resolution. Lynne Spryszak, RN, CCDS, CPC-A, CDI education director at HCPro, Inc., in Danvers, MA, included this chart in her 2010 audio conference presentation "Physician Queries Workshop: Tools and Techniques for Compliant, Effective Clarification."

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Common secondary diagnoses reference tool--2011 MCCs, 2-2-11

Attached is a common secondary diagnoses reference tool. The indicated diagnoses are all major complications/comorbidities (MCCs), updated for fiscal year 2011. Amanda Suggs created the original tool and it was updated by Donna Wilson of Compliance Concepts, Inc.

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Sample chart review worksheet 1.7.11

The attached sample chart review worksheet, provided by Lynne Spryszak, RN, CCDS, CPC-A, is intended to provide a helpful example of a form that can be used to record notations and findings during daily chart review duties.

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CDI training powerpoint for new hospitalists 1.5.11

Courtesy of Tulane University Hospital and Clinic, the attached powerpoint presentation is a sample training tool for new hospitalists. It provides an introduction to CDI and education on a handful of problematic diagnoses.

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Toxic Metabolic Encephalopathy powerpoint presentation

The attached powerpoint presentation is a training tool for recognizing clinical indicators of toxic metabolic encephalopathy. It was presented for a local ACDIS chapter by John W. Melton, MD.

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Top Five Documentation and Coding Challenges powerpoint: Complications

Attached is a Top Five Documentation and Coding Challenges powerpoint presentation, as prepared by James Kennedy and Margi Brown for HCPro, Inc. It is provided here as a reference tool for complications of surgery and was referenced during the November 18, 2010 ACDIS quarterly conference call.

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Top Five Documentation and Coding Challenges powerpoint: ARF

Attached is a Top Five Documentation and Coding Challenges powerpoint presentation, as prepared by James Kennedy and Margi Brown for HCPro, Inc. It is provided here as a reference tool for acute renal failure and was referenced during the November 18, 2010 ACDIS quarterly conference call.

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Sample educational posters for CHF, pneumonia, malnutrition

Jennifer Love, RN, BA, CCDS, manager of clinical documentation specialists at Novant Health in North Carolina, shares a physician education flyers regarding congestive heart failure, pneumonia, and malnutrition. Adopt these Power Point slides to your facility's documentation clinical indicators and use them as posters to help focus physician attention on these commonly under documented conditions.

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CDI staff orientation checklist

Sandra Beatty, RN, BSN, C-CDI, CCDS, earned the 2010 CDI Professional of the Year Award from her peers at ACDIS. Since then she's kept on providing innovative tools for the CDI program at her faciltiy Columbus Regional Hospital, in Indiana.

She created this spreadsheet as a to cross-train the facility's Recovery Audit Contractor team nurses to CDI but expanded the training checklist for anyone involved in the documentation improvement process.

The checklist includes a list of items that CDI should receive training about and provides a place to indicate when the education session took place, the participant and preceptor's initials, as well as a spot for additional comments and a section for the individual's manager to follow-up within 90 days to check on the individual's continued understanding of the subject matter.

Note that this checklist is based on the work of Deborah Dallen, RN, Clinical Documentation Coordinator for Albert Einstein Medical Center in Philadephia.

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Physician education: BMI flyer

Jennifer Love, RN, BA, CCDS, manager of clinical documentation specialists at Novant Health in North Carolina, shares a physician education flyer regarding which reminds physicians that a BMI greater than 40 constitutes morbid obesity.

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Sample Query: Signs and Symptoms

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 Norbeck of St. Rita's Medical Center in Lima, OH, to help remind physicians that more than symptoms are needed to accurately reflect the care provided to the patient.

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Sample Query: Staging for Chronic Renal Failure

The attached documentation form regarding staging for chronic renal failure 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 medical staff.

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Sample Query: Unspecified chest pain

The attached documentation clarification form regarding unspecified chest pain 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 medical staff.

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Sample Query: Congestive Heart Failure

The attached congestive heart failure 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 medical staff.

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Sample Query: Debridement

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 medical staff.

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Sample CDI flexible schedule

A sound CDI program can’t be built on the needs of a single staff member, regardless of his or her qualifications, you have to build the business case for a flexible schedule based on the program’s overarching needs and the benefit of that role to the facility.

Melanie Halpern, RN-BC, MBA, CCDS, CCRA, University of Medicine and Dentistry of New
Jersey (UMDNJ) and Marion Kruse, RN, MBA, director at FTI Healthcare in Atlanta created an Excel spreadsheet to map out three different options for flexible scheduling :

  • Three full time equivelent (FTE) staff working four 10-hour days
  • Three 12-hour shifts
  • A typical five-day, 7.5-hour-per-day schedule

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CDI specialists’ tool kit

Attached is a list of websites that CDI specialists can use to help stay on top of regulatory changes, audit reports, coding and documentation updates, the latest clinical information, and more, courtesy of Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, director of Clinical Documentation Improvement Services for YPRO Corporation and a member of the ACDIS advisory board.

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Debridement documentation flyer

The attached debridement documentation flyer was provided by Trish Talton, RN, BSN, Clinical Documentation Improvement Specialist with WakeMed Health and Hospitals. It is intended to be printed out and posted in a visible area as a reminder for physicians to document excisional vs. non-excisional debridement.

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Renal failure documentation guide

Robert S. Hodges, BSN, MSN, RN, Clinical Documentation Improvement Specialist, at Aleda E. Lutz VAMC, in Saginaw, MI, offered this sample renal failure documentation guide which includes the National Kidney Foundation definations for Chronic Kidney Disease as well as the “RIFLE” criteria commonly used to classify Acute Kidney Failure or injury. It can be printed on a single sheet of paper and folded to use as an education handout for physicians. It is intended as a sample only and any diagnostic criteria should meet the approval of your medical staff.

 

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2010 Conference: Death review and SOI/ROM

Attached is the powerpoint presentation The Power of Case Studies: Death Review and SOI/ROM, as presented by Cheryl Ericson, MS, RN, Manager of Clinical Documentation Integrity and Utilization Review at Medical University of South Carolina.

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2010 Conference: Spotlight on Compliance

Attached is the powerpoint presentation CDI in 2010: Spotlight on Compliance as presented by Gloryanne Bryant, RHIA, RHIT, CCS, CCDS and Catherine O’Leary, RN, BSN.

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2010 Conference: Gray Areas in CDI

Attached is the powerpoint presentation Gray Areas in CDI: Negotiating the Relationship, as presented by James S. Kennedy, MD, CCS, Managing Director, FTI Healthcare.

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2010 Conference: CMS Outcome Indicators Methodology, Risk Adjustment, & Strategy

Attached is the powerpoint presentation CMS Outcome Indicators Methodology, Risk Adjustment, & Strategy as presented by Kristen Geissler, MS, PT, CPHQ, MBA, Associate Director, Navigant Consulting, Inc.

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2010 Conference: Care Documentation as a Clinical Process

Attached is the powerpoint presentation Best Practices at University of Washington Medical Center: Care Documentation as a Clinical Process, as presented by Mel Tully, MSN, CCDS, and Holly Flynn, RN, CCRN.

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2010 Conference: CDI and the ED

Attached is the powerpoint presentation CDI and the ED: Understand Physician Thinking to Conquer Documentation Challenges, as presented by Pamela Bensen, MD, MS, FACEP, of Medical Education Programs, Inc.

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2010 Conference: Ethics ends with the clarification

Attached is the powerpoint presentation Ethics ends with the clarification, as presented by Robert Gold, MD, CEO of DCBA, Inc.

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2010 Conference: Clinical Potpurri: A Review of Problematic Diagnoses

Attached is the powerpoint presentation Clinical Potpurri: A Review of Problematic Diagnoses, as presented by William Haik, MD, Director of DRG Review, Inc.

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2010 Conference: Bring CDI to your Emergency Department STAT!

Attached is the powerpoint presentation Bring CDI to your Emergency Department STAT!, as presented by Laurie Cianfrini, RN, Corporate Manager, Clinical Documentation Specialists for Kaleida Health.

 

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2010 Conference: CDI and the RAC an Update on the Permanent Program

Attached is the powerpoint presentation CDI and the RAC: Lessons Learned from the Demonstration and an Update on the Permanent Program, as presented by Ann-Marie Carducci, RN, CCS, CPC, CPHQ, CPUR, Director, Utilization Management, Montefiore Medical Center.
 

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2010 Conference: Creating a Point-of-Entry Clinical Documentation Specialist/Case Manager

Attached is the powerpoint presentation Creating a Point-of-Entry Clinical Documentation Specialist/Case Manager, as presented by Kathleen A. Bower, DNSc, RN, FAAN, Arinda F. Kennedy, RN, CCDS, The Center for Case Management, Wellesley, MA.
 

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2010 Conference: The clinical/coding reconciliation process

Attached is the powerpoint presentation Bridging the CDI gap: Bringing the clinical/coding reconciliation process together, as presented by Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS, and Lynne Spryszak, RN, CCDS, CPC-A.
 

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2010 Conference: Finding the Key to Success: Adapting to the EHR

Attached is the powerpoint presentation Finding the Key to Success: Adapting to the EHR, as presented by Katie Miller, RHIA, MA, and Michelle Callahan, RN, BSN, CCDS, Hennepin County Medical Center in
Minneapolis, MN.

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2010 Conference: Inpatient Medicare Advantage: HCC Capture Through CDI

Attached is the powerpoint presentation Inpatient Medicare Advantage: HCC Capture Through CDI, as presented by Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS, Regional Managing Director of HIM, NCAL Revenue Cycle Kaiser Foundation and Hospitals.

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2010 Conference: Data Mining and Reports, Using Data to Drive your Program

Attached is the powerpoint presentation Data Mining and Reports, Using Data to Drive your Program, as presented by Maureen Baxley, RRT, RN, BSN,Clinical Documentation Nurse, Carla Henderson, RRT, RN, BSN, Clinical Documentation Nurse, and Nancy R. Ignatowicz, RN, MBA, CCDS, System Manager Clinical Documentation all of Provena Covenant Medical Center.

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2010 Conference: Role of the physician champion

Attached is the powerpoint presentation Role of the physician champion, as presented by Richard S. Eisenstaedt, MD, FACP.

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2010 Conference: Strategies for achieving medical staff compliance

Attached is the powerpoint presentation Strategies for achieving medical staff compliance, as presented by Trey La Charité, MD, CDI Program Physician Advisor, Hospitalist, Clinical Assistant Professor, University of Tennessee Medical Center at Knoxville.
 

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2010 Conference: Physician Education Catch Them and Hold Them

Attached is the powerpoint presentation CDI Physician Education Catch Them and Hold Them, as presented by Monica Dancu, RN, BSN, Sylvia Hoffman, RN, Darlene Shelffo, RN, CCDS, CDI Manager at Tampa (FL) General Hospital.

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2010 Conference: From the Bedside to the Business Side

Attached is the powerpoint presentation From the Bedside to the Business Side of CDI, as presented by Natalie Leagan, RN, BSN, CCDS.

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2010 Conference: Understanding the Role of Performance Mapping

Attached is the powerpoint presentation Understanding the Role of Performance Mapping for CDI, as presented by Darice Grzybowski, MA, RHIA, FAHIMA, HIMentors and John (JT) Trusten, Knowledge Webb Healthcare.

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2010 Conference: Managing CDI Staff Across Multiple Campuses

Attached is the powerpoint presentation Managing CDI Staff Across Multiple Campuses, as presented by Lena N. Wilson, MHI, RHIA, CCS, HIM Operations Manager, Clinical Documentation Improvement Program for five hospitals in the Clarion Health in Indiana.

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Physician education: Congestive heart failure

At Emerson Hospital in Concord, MA, CDI Specialist Patty Spry, RN, snuck in a little physician education for congestive heart failure (CHF) by including important clinical standards on the reverse side of the facility’s standard CHF query form.

The supporting information defines an acute condition as a first event, acute on chronic as subsequent events and chronic as a condition maintained by any combination of medications (and Emerson lists the medications).

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Query Form for Congestive Heart Failure

At Emerson Hospital in Concord, MA, CDI Specialist Patty Spry, RN, sneeks in a little physician education for congestive heart failure (CHF) by including important clinical standards on the reverse side of the facility’s standard CHF query form. 

“We have had success with getting docs to define CHF that ways,” Spry says.

The front, or query portion, of the form addresses the specific physician and the date of the query. It then asks the physician to reference the supporting information on the back of the form to clarify in his/her progress note and discharge summary the nature and acuity of the CHF.
 

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Kidney Disease Query

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 System offers the following kidney disease clarification form as a sample for other facilities to adopt to their needs. Included in the query are definations of AKI/ARF, CKD stages, ESRD.

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Kidney Disease Clarification

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 System offers the following kidney disease clarification form as a sample for other facilities to adopt to their needs.

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Sample CDI Newsletter: Acute Renal Failure

Robert S. Hodges, BSN, MSN, RN, Clinical Documentation Improvement Specialist at Aleda E. Lutz VAMC in Saginaw, MI, offers the following sample CDI newsletter, essentially a letter from the CDI group to the physicians offering a personal antecdote or message that then leads into more specific documentation tips for a particular clinical diagnosis. This sample newsletter offers tips on acute renal failure. It is intended as a sample only and any diagnostic criteria should meet the approval of your medical staff.

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Sample CDI Newsletter: Sepsis Documentation

Robert S. Hodges, BSN, MSN, RN, Clinical Documentation Improvement Specialist at Aleda E. Lutz VAMC in Saginaw, MI, offers the following sample CDI newsletter, essentially a letter from the CDI group to the physicians offering a personal antecdote or message that then leads into more specific documentation tips for a particular clinical diagnosis. This sample newsletter offers tips on sepsis. It is intended as a sample only and any diagnostic criteria should meet the approval of your medical staff.

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Policy: Standard Operating Procedure for Provider Queries

 

Robert S. Hodges, BSN, MSN, RN, Clinical Documentation Improvement Specialist at Aleda E. Lutz VAMC in Saginaw, MI, offers the following sample standard operating procedure (SOP) for physician queries. It outlines basic definations of reportable conditions, clinically significant conditions, healthcare providers, query types, and query expectations. This should be used as a sample for your facility. CDI programs should customize their own policies and procedures based on involvement from a variety of CDI stakeholders including compliance, health information management, medical staff, and finance, among others, whenever possible.

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Good Documentation Certificate pdf

Susan Borrego, MSN, RN, CCDS, and Michelle Limo, MSMIT, RN, CCDS represent the two-person team that is the Salinas Valley Memorial Healthcare (SVMH) System’s clinical documentation improvement (CDI) department developed this congratulatory certificate for physicians when they provide specific and accurate documentation without being queried. The certificate is printed in color and placed in the medical chart for all clinicians to see while the patient is still in-house. This is the pdf version of the document.

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Documentation clarification form: Tamponade

This attached form includes a clarification request for tamponade, including sourced definitions. It is intended as a sample only and any diagnostic criteria should meet the approval of your medical staff.

This is courtesy of Sandy Beatty, clincial documentation specialist for Columbus Regional Hospital.

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Documentation clarification form: Sepsis

This attached form includes a clarification request for sepsis, including sourced definitions. It is intended as a sample only and any diagnostic criteria should meet the approval of your medical staff.

This is courtesy of Sandy Beatty, clincial documentation specialist for Columbus Regional Hospital.

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Documentation clarification form: Respiratory failure

This attached form includes a clarification request for respiratory failure, including sourced definitions. It is intended as a sample only and any diagnostic criteria should meet the approval of your medical staff.

This is courtesy of Sandy Beatty, clincial documentation specialist for Columbus Regional Hospital.

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Documentation clarification form: HTN

This attached form includes a clarification request for HTN (hypertension, heart and kidney), including sourced definitions. It is intended as a sample only and any diagnostic criteria should meet the approval of your medical staff.

This is courtesy of Sandy Beatty, clincial documentation specialist for Columbus Regional Hospital.

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Documentation clarification form: CHF

This attached form includes a clarification request for congestive heart failure (CHF), including sourced definitions. It is intended as a sample only and any diagnostic criteria should meet the approval of your medical staff.

This is courtesy of Sandy Beatty, clincial documentation specialist for Columbus Regional Hospital.

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Documentation clarification form: Stages of renal failure

This attached form includes a clarification request for stages of renal failure, including sourced definitions. It is intended as a sample only and any diagnostic criteria should meet the approval of your medical staff.

This is courtesy of Sandy Beatty, clincial documentation specialist for Columbus Regional Hospital.

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Documentation clarification form: MI

This attached form includes a clarification request for myocardial infarction (MI), including sourced definitions. It is intended as a sample only and any diagnostic criteria should meet the approval of your medical staff.

This is courtesy of Sandy Beatty, clincial documentation specialist for Columbus Regional Hospital.

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Documentation clarification form: Malnutrition

This attached form includes a clarification request for malnutrition, including sourced definitions. It is intended as a sample only and any diagnostic criteria should meet the approval of your medical staff.

This is courtesy of Sandy Beatty, clincial documentation specialist for Columbus Regional Hospital.

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Documentation clarification form: Cardiogenic shock

This attached form includes a clarification request for cardiogenic shock, including sourced definitions. It is intended as a sample only and any diagnostic criteria should meet the approval of your medical staff.

This is courtesy of Sandy Beatty, clincial documentation specialist for Columbus Regional Hospital.

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Good Documentation Certificate

Susan Borrego, MSN, RN, CCDS, and Michelle Limo, MSMIT, RN, CCDS represent the two-person team that is the Salinas Valley Memorial Healthcare (SVMH) System’s clinical documentation improvement (CDI) department developed this congratulatory certificate for physicians when they provide specific and accurate documentation without being queried. The certificate is printed in color and placed in the medical chart for all clinicians to see while the patient is still in-house.

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Renal documentation clarification form

The attached sample renal documentation clarification form is provided by Sandy Beatty, RN, BSN, C-CDI, clinical documentation specialist for Columbus Regional Hospital.

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Sample policy: Unanswered query followup process

The attached sample policy describes a process for addressing unanswered physician queries.

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Good documentation letter

At St. Mary's Hospital in Passaic, NJ, Melanie Halpern, RN-BC, MBA, CCDS, Clinical Documentation Specialist, helped develop a “good documentation” letter to congratulate physicians on their documentation efforts, complete with a little “A+” graphic in the upper right-hand corner.

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FY 2010 CC list

Attached is the fiscal year (FY) 2010 list of complications/comorbidities (CCs).

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Concurrent core measures advisory form

The attached concurrent core measures advisory form is intended for use for CDI programs involved in core measures documentation. The form is courtesy of Melanie Halpern, RN-BC, MBA, CCDS, and St. Mary's Hospital in Passaic, NJ.

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Heart failure query form

This sample heart failure query form helps physicians specify the type of heart failure through easy to use check boxes.

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CDI specialist orientation: MDC review sheet

The attached MDC Review Checklist, provided by Deborah Dallen, RN, Clinical Documentation Coordinator for Albert Einstein Medical Center in Philadephia, is intended as a tool for a preceptor to sign off that each MDC was reviewed with the CDI specialist orientee.

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CDI specialist orientation checklist

The attached CDI specialist orientation checklist, provided by Deborah Dallen, RN, Clinical Documentation Coordinator for Albert Einstein Medical Center in Philadephia, is provided as a reference for getting new CDI specialists up to speed and trained.

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DRG Decision Tree

The attached DRG Decision Tree provides a flowchart explaining how DRGs are assigned, based on V26.0 of the 3M MS-DRG Definitions Manual.

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Palliative Care Sample Query form

Attached is a sample palliative care query form, provided by Rush University Medical Center.

Note that this form is intended for use in the Epic electronic record. Per Rush Univeristy Medical Center:

  • We add to the query any additional supporting information indicated by the record (e.g., DNR/DNI status). 
  • Because we have a totally electronic record (Epic), we have educated MDs and also developed an Epic Smart Phrase to support their documentation. The Smart Phrase is:
Palliative Care/Comfort Care: Goals of care have been discussed with _____________ regarding this patient with _______________ disease. A decision [has been made/was made] to begin Palliative Care/Comfort Care starting _______________

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Altered mental status query form

The attached document provides a sample query form for clarifying physician documentation of altered mental status in order to arrive at a more specific diagnosis, such as encephalopathy. The form was developed by James Kennedy, MD, CCS, of FTI Healthcare and is designed to comply with the recommendations of the American Health Information Management Association (AHIMA).

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Heart Failure Progress Note

Mease Countryside and Mease Dunedin hospitals in Florida pilot-tested the evidence based measures (EBM) progress notes for their CDI physician queries. Use the progress note to capture information up front for coding as well as quality measurement purposes.

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2009 ACDIS conference attendee list

Attached is the 2009 ACDIS conference attendee list, sorted by name and organization.

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Physician documentation clarification 2009 ACDIS conference

Attached is the powerpoint presentation Physician documentation clarification: A coding, clinical, and patient safety perspective, as presented by Andrew Dombro, Mario Perez, and Mel Tully at the 2009 ACDIS conference.

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Sepsis and respiratory failure 2009 ACDIS conference

Attached is the powerpoint presentation Challenges in critical care: Sepsis and respiratory failure, as presented by William Haik at the 2009 ACDIS conference.

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Managing a clinical documentation department to excellence 2009 ACDIS conference

Attached is the powerpoint presentation Managing a clinical documentation department to excellence, as presented by Randi Ferrare at the 2009 ACDIS conference.

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A clinical documentation success story 2009 ACDIS conference

Attached is the powerpoint presentation A clinical documentation program success story five years after implementation, as presented by Terry Bakowicz and Jill Dressler at the 2009 ACDIS conference.

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Understanding Medicare’s quality indicators 2009 ACDIS conference

Attached is the powerpoint presentation Understanding Medicare's quality indicators, as presented by Kristen Geissler at the 2009 ACDIS conference.

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What not to ask physicians 2009 ACDIS conference

Attached is the powerpoint presentation What not to ask physicians, as presented by Robert Gold at the 2009 ACDIS conference.

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New analytics for new DRGs 2009 ACDIS conference

Attached is the powerpoint presentation New analytics for new DRGs: Using business intelligence tools to support a measurement program for documentation and coding improvement, as presented by Dave Caplan at the 2009 ACDIS conference.

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The RAC experience 2009 ACDIS conference

Attached is the powerpoint presentation The RAC experience: Use your CDI program to proactively address the RAC audits, as presented by Catherine O'Leary at the 2009 ACDIS conference.

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Forms and tools workshop 2009 ACDIS conference

Attached is the powerpoint presentation Forms and tools workshop, as presented by Gloryanne Bryant at the 2009 ACDIS conference.

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A focus on severity and risk of mortality 2009 ACDIS conference

Attached is the powerpoint presentation Hospitals cannot live by DRGs alone: A focus on severity of illness and risk of mortality, as presented by Tamara Hicks at the 2009 ACDIS conference.

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Teaching physicians "What’s in it for me" 2009 ACDIS conference

Attached is the powerpoint presentation Teaching physicians "What's in it for me" (WIIFM), as presented by Margi Brown at the 2009 ACDIS conference.

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Renal disease: 2009 ACDIS conference

Attached is the powerpoint presentation Renal disease, as presented by Robert Gold at the 2009 ACDIS conference.

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Restarting or revamping your CDI program: A case study 2009 ACDIS conference

Attached is the powerpoint presentation Restarting or revamping your CDI program: A case study, as presented by Catherine O'Leary and Colleen Garry at the 2009 ACDIS conference.

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Critical chart analysis: 2009 ACDIS conference

Attached is the powerpoint presentation Critical chart analysis: How and where to identify opportunities in a DRG-based CDI program, as presented by Lynne Spryszak at the 2009 ACDIS conference.

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Case study: University of Tennessee Medical Center at Knoxville 2009 ACDIS conference

Attached is the powerpoint presentation Case study: University of Tennessee Medical Center at Knoxville, as presented by Martha Collins, Trey La Charite, Lisa Peterson, and Carla Stump at the 2009 ACDIS conference.

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Identifying the clinical "hidden agenda" in the medical record 2009 ACDIS conference

Attached is the powerpoint presentation Identifying the clinical "hidden agenda" in the medical record, as presented by Glenn Krauss and Gamal Eskander at the 2009 ACDIS conference.

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Things you thought you knew about ICD-9-CM coding 2009 ACDIS conference

Attached is the powerpoint presentation Things you thought you knew about ICD-9-CM coding--but may not, as presented by Shannon McCall at the 2009 ACDIS conference.

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AHIMA physician query practice brief 2009 ACDIS conference

Attached is the powerpoint presentation AHIMA physician query practice brief: Maintain compliance with new guidelines, as presented by Gloryanne Bryant at the 2009 ACDIS conference.

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Training presentation: Pediatric documentation opportunities

Susan Klein, RN, director of clinical documentation management at Saint Peter’s University Hospital in New Brunswick, NJ, recently found some interesting and rewarding documentation opportunities in an area many CDI specialists overlook: the pediatric unit.

Klein shares her power point presentation regarding documentation improvement on the pediatric unit with ACDIS members.

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Policy and procedure: Clarification of compliant query process

The attached document provides a sample process for clarifying physician documentation whenever there is conflicting, ambiguous, or incomplete information in the medical record regarding any significant reportable condition or procedure.

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Policy and Procedure: CDI Position Statement

Purpose: Complete and accurate diagnostic and procedural coded data is necessary for communication of patient's treatment plan, evaluation of the quality of care rendered, reimbursement, financial and strategic planning, outcomes and statistical analyses, epidemiology and research. Clinical Documentation Improvement professionals must continue to meet the challenges of contributing to an accurate and meaningful database that clearly defines both the patient mix and the use of resources. Assuring the accuracy of coded data is a shared responsibility between the Clinical Documentation Specialists, Health Information Management professionals and clinicians

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Policy and Procedure: Final Coding Decisions in CDI

Policy: When officially recognized coding resources do not address the question at hand, the Clinical Documentation Specialist should raise the question for discussion amongst the coders, DRG Analyst, physician advisor and/or Coding Manager, and Clinical Documentation staff members.

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Policy and Procedure: Compliance practices in CDI

Purpose: To establish Clinical Documentation Improvement compliance practices. There are department policies and procedures related to the Clinical Documentation Management Program which are located in the departmental policies and procedure manual.

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Policy and Procedure: Physician Inpatient Query Process

Scope and Purpose of Policy: To clarify physician documentation whenever there is conflicting, ambiguous, or incomplete information in the medical record regarding any significant reportable condition or procedure.

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MD documentation tip sheet

This attached documentation tip sheet is designed to be printed out and used as a pocket reference for physicians.

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Training e-mail: Diagnosing X-Ray findings

Training: Sample e-mail regarding physician documentation for diagnosing x-ray findings courtesy of Mike Alcorn, LVN, director of clinical documentation improvement at North Cypress (TX) Medical Center.

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Training e-mail: G.I. Hemorrhage and Anemia

Training: Sample e-mail regarding physician documentation for G.I. Hemorrhage and Anemia courtesy of Mike Alcorn, LVN, director of clinical documentation improvement at North Cypress (TX) Medical Center.

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Training e-mail: History of CVA vs. late effects

Training: Sample e-mail regarding physician documentation for history of CVA vs. late effects that can be coded courtesy of Mike Alcorn, LVN, director of clinical documentation improvement at North Cypress (TX) Medical Center.

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Training e-mail: Heart Failure-Drop the C and add the D or S

Training: Sample e-mail regarding physician documentation for chronic heart failure, drop the C for chronic and add the D for dystolic, courtesy of Mike Alcorn, LVN, director of clinical documentation improvement at North Cypress (TX) Medical Center. Effective October 1, 2007 “CHF” was removed as a comorbid condition from coding guidelines. In order for heart failure to be listed as a comorbid condition, it must be diagnosed with severity and type of heart failure.

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Training e-mail: CHF

Training: Sample e-mail regarding physician documentation for chronic heart failure courtesy of Mike Alcorn, LVN, director of clinical documentation improvement at North Cypress (TX) Medical Center. Secondary diagnosis are more important than ever before. Most chronic conditions do not increase severity. However, in the case of heart failure it does.

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Training e-mail: Cardiac/circulatory system diagnosis

Training: Sample e-mail regarding physician documentation regarding cardiac/circulatory system diagnosis, courtesy of Mike Alcorn, LVN, director of clinical documentation improvement at North Cypress (TX) Medical Center.

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Debridement documentation form

This sample debridement documentation form is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

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Pneumonia documentation form

This sample pneumonia documentation form is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

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Gastroenteritis documentation form

This sample gastroenteritis documentation form is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

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Respiratory documentation form

This sample respiratory documentation form is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

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Pressure ulcer staging, POA status form

This sample pressure ulcer staging and POA status form is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

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Anemia documentation form

This sample anemia documentation form is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

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Kidney disease documentation

This sample kidney disease documentation form is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

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Malnutrition progress note

This sample malnutrition progress note is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

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Adult BMI documentation

This sample adult BMI documentation form is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

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CHF progress note

This sample CHF progress note is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

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Present on admission documentation form

This sample present on admission documentation form is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

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Physician liaison contract and sample job description

This sample contract and physician liaison job description from Robert Gold, MD, contains language you can adapt to your facility’s needs. Make sure to share these contracts with your facility attorney.

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Clinical Documentation Review Worksheet

Use this sample to review your clinical documentation.

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Physician advisor job description

This job description, provided by Robert Gold, MD, of DCBA, Inc., provides a job description for a physician advisor within a CDI program.

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Discharge summary educational flyer

Courtesy of Linda Haynes and the CDI program of Meridian Park Hospital, the attached CHF educational flyer can be printed out and posted in physician lounges, lunch rooms, dictation areas, and the like.

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Documentation improvement tips flyer

Courtesy of Linda Haynes and the CDI program of Meridian Park Hospital, the attached documentation improvement tips flyer can be printed out and posted in physician lounges, lunch rooms, dictation areas, and the like.

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CHF educational poster

Courtesy of Linda Haynes and the CDI program of Meridian Park Hospital, the attached CHF educational flyer can be printed out and posted in physician lounges, lunch rooms, dictation areas, and the like.

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Pneumonia pocket guide

This pneumonia pocket guide, provided by Gloryanne Bryant, RHIA, RHIT, CCS, corporate director of Coding/HIM Compliance for Catholic Healthcare West, is designed to help physicians document the important aspects of pneumonia in order to comply with Medicare and other regulatory standards. Note that this is a proprietary business document and is meant as an example for developing your own forms.

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Anemia sample query form

The attached anemia query form is courtesy of Lakeland Regional Medical Center. It was developed by a team consisting of four clinical documentation specialists, the CDI program manager, a physician advisor, and supervisor of the inpatient coding department. 

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CKD sample query form

The attached CKD query form is courtesy of Lakeland Regional Medical Center. It was developed by a team consisting of four clinical documentation specialists, the CDI program manager, a physician advisor, and supervisor of the inpatient coding department. 

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CHF sample query

The attached CHF query form is courtesy of Lakeland Regional Medical Center. It was developed by a team consisting of four clinical documentation specialists, the CDI program manager, a physician advisor, and supervisor of the inpatient coding department. 

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Clinical documentation specialist job description/performance evaluation

Attached is a sample combined job description/performance evaluation for a clinical documenation specialist.

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Pressure Ulcer MS-DRG Update Memo

As of October 2008, Clinical Documentation Improvement Specialists have a new opportunity to capture severity of illness with the documentation of pressure ulcers, the stage of the ulcer, and notation of whether the ulcer was present on admission. This form, developed by Gail Marini of South Shore Hospital, helps CDI specialists capture the necessary documentation.

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Sepsis query form

Attached is a sample query form for obtaining more specific documentation on sepsis, as provided by Wendy Dougherty of Mercy Medical Center in Nampa, ID.

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CKD query form

Attached is a sample query form for obtaining more specific documentation on chronic kidney disease, as provided by Wendy Dougherty of Mercy Medical Center in Nampa, ID.

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CHF query form

Attached is a sample query form for obtaining more specific documentation on congestive heart failure, as provided by Wendy Dougherty of Mercy Medical Center in Nampa, ID.

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MCC pocket guide

Attached is a tip card to help clinical documentation specialists capture major complications/comorbidities, as provided by Amanda Suggs of Roper St. Francis hospital. She notes that it should be shrunken to pocket size and laminated front and back to serve as a pocket guide.

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Documentation clarification worksheet for respiratory symptoms

Attached is a sample documentation clarification worksheet for respiratory symptoms, to assist physicians with documentation of acute respiratory failure when appropriate.

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Physician liaison champion job description

Attached is a job description for a physician liaison/physician champion position, as submitted by Gloryanne Bryant of Catholic Healthcare West.

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2008 ACDIS conference attendee list

Attached is the attendee list of the 2008 ACDIS annual conference, sorted by name and organization.

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The Coding Clinical Documentation Link 2008 ACDIS conference

Attached is the powerpoint presentation The Coding/Clinical Documentation Link, as presented by Heather Taillon at the 2008 ACDIS conference.

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Kindred Healthcare case study 2008 ACDIS conference

Attached is the powerpoint presentation Case Study: Kindred Healthcare LTAC Hospital System, as presented by Pam Lovell and Wendy De Vregud at the 2008 ACDIS conference.

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Clarian Health Partners case study, 2008 ACDIS conference

Attached is the powerpoint presentation Case Study: Clarian Health Partners, Indianapolis, Developing and Implementing a CDI Program in a Multifacility, Academic, Level 1 Trauma Center, as presented by Marijane Armbruster and Lena Wilson at the 2008 ACDIS conference.

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Data Mining and Reporting 2008 ACDIS conference

Attached is the powerpoint presentation Data Mining and Reporting, as presented by Colleen Garry at the 2008 ACDIS conference.

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Building Physician Relationships 2008 ACDIS conference

Attached is the powerpoint presentation Building Physician Relationships, as presented by Robert Gold at the 2008 ACDIS conference.

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Physician queries--Medical Univeristy South Carolina case study 2008 ACDIS conference

Attached is the powerpoint presentation Physician Queries and Communication--Medical University of South Carolina Case Study, as presented by Pam Parris and Jacqueline Robinson at the 2008 ACDIS conference.

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Heart failure 2008 ACDIS conference

Attached is the powerpoint presentation Heart Failure, as presented by Robert Gold at the 2008 ACDIS conference.

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Case study Roper St. Francis 2008 ACDIS conference

Attached is the powerpoint presentation Case Study: Roper St. Francis, as presented by Jean Clark at the 2008 ACDIS conference.

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Present on Admission 2008 ACDIS conference

Attached is the powerpoint presentation Present on Admission, as presented by Shannon McCall at the 2008 ACDIS conference.

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Physician queries and compliance 2008 ACDIS conference

Attached are the powerpoint slides for Physician Queries and Compliance, a session presented by Gloryanne Bryant at the 2008 ACDIS conference.

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Medicare Severity DRGs (MS-DRGs): 2008 ACDIS conference

Attached is the powerpoint presentation Medicare Severity DRGs (MS-DRGs), as presented by Gloryanne Bryant at the 2008 ACDIS conference.

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Pneumonia query form

The attached document provides a sample query form to help specify types of pneumonia.

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MS-DRGs MCC tip card

This attached form is a tip card for CDI specialists to help them reference common major complications/comorbidities (MCCs). It is not a comprehensive list.

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MS-DRGs handout for dictation areas

This sample form is intended to be posted in physician dictation areas in order to educate physicians on documentation requirements under MS-DRGs.

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CDI Manager job description

The attached document provides a sample job description of a CDI manager who oversees a CDI department.

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Diagnosis specificity policy

This attached diagnosis specificity policy offers guidelines for coding conditions with nonspecific and specific terms.

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Backend communication request form

Attached is a sample form to assist with backend communication between coders and clinical documentation specialists.

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Auditor-Coder-CDS communication form

The attached form provides a sample policy on establishing lines of communication between auditors, clinical documentation specialists, and remote coding staff.

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Wound debridement query form

Attached is a sample wound debridement query form.

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Clinical documentation specialist job description

Attached is a sample clinical documentation specialist job description.

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Pressure ulcer physician notification form

This form, provided by Dawn Diven, BSN, RN, documentation specialist for Western Maryland Health System in Cumberland, MD, is a sample documentation form for physicians to confirm wound assessments and descriptions by nursing staff. As the nurse files the history and physical it is generated and placed into the physician's progress notes to sign. This report is from a chart and is not ready to use, but is proivded here as an example for other hospitals to consider.

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Excisional debridement physician query form

This form, provided by Gloryanne Bryant, RHIA, CCS, senior director of corporate coding/HIM compliance for Catholic Healthcare West in San Francisco, CA, is a template to query physicians regarding the type of debridement they have performed (excisional vs. non-excisional). Note that this is a proprietary business document and information on reprint permission may be found at the bottom of the form.

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Sample clinical documentation improvement chart

This sample chart, provided by Wendy De Vreugd, senior director of case management, west group, for Kindred Healthcare, provides an excel spreadsheet for tracking the impact a clinical documentation improvement specialist can have on a hospital’s case-mix index. See "Key to sample clinical documentation improvement chart" for an explanation of its use.

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Clinical documentation consultant job description

This job description, provided by Tamara Hicks of North Carolina Baptist Hospital, provides a sample job summary, primary accountabilities, and job specifications of a clinical documentation specialist.

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Clinical documentation manager job description

Clinical documentation manager job description

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Job description: Role of the concurrent documentation specialist

This attachment, provided by William E. Haik, MD, of DRG Review, Inc., is a sample job description of a clinical documentation improvement specialist.

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Physician query form: Pneumonia

This attached form, provided by Gloryanne Bryant, corporate director of coding/HIM compliance for Catholic Healthcare West, helps clinical documentation improvement specialists clarify for simple vs. complex pneumonia.

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Physician query form: Diabetes

This attached form, provided by Gloryanne Bryant, corporate director of coding/HIM compliance for Catholic Healthcare West, helps clinical documentation improvement specialists query for specific types of diabetes.

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Clinical documentation gold standards card

This form provides one facility's "gold standard" of what clinical documentation improvement specialists should strive for in order to ensure accurate, complete, physician documentation in the record.

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ACDIS annual conference

ACDIS annual conference


Blue card: Abnormal tests

Attached is a sample query form designed to help physicians better document abnormal tests in the record.

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Blue card: Bacteremia sepsis

Attached is a sample physician query form designed to help clarify urosepsis vs. septicemia in the record.

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Blue card: Document sepsis

Attached is a sample physician query form designed to clarify clinical evidence of sepsis in the medical record.

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Heart failure chart

Attached is a heart failure chart designed to help clinical documentation improvement specialists identify signs and symptoms of heart failure in the medical record.

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Chronic kidney disease query form

Attached is a sample chronic kidney disease (CKD) physician query form designed to help physicians properly document the stage of a patient's CKD.

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POA query form

Attached is a sample query form designed to help physicians properly document any diagnoses that are present on admission.

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