The attached Word document contains a proposal for mandatory physician education regarding facility CDI practices. Created by Rebecca "Ali" Williams, RN, BSN, CCDS, this document can be adapted and brought forward to your facility's medical staff director or your program director to foster the ongoing training of incoming physicians.

The attached Word document reviews documentation and coding needs for complications and establishes policies and procedures for coders and CDI professionals to follow. Created by Paul Evans, RHIA, CCS, CCS-P, CCDS, the document provides complication definitations, explains when queries should be issued, and explores specific documentation concerns regarding coditions such as Incidental Serosal Tear and postoperative atrial fibrillation.

See also coding complications training PowerPoint presentation in the Education & Training section of the Forms & Tools Library.

This document exlains how to query for encephalopathy when ''acute delirium'' is well documented in the chart. It was provided by Cindy Prayzner at South Coast.
 

This document is a formal approach to documenting postoperative respiratory failure. It is provided by Paul Evans, RHIA, CCS, CCS-P, CCDS, of Sutter Health in San Francisco

This is a mortality review spreadsheet that lists age, unit, DRG, SOI/ROM scores, Pdx, mcc/cc’s, secondary dx’s, DNR/Palliative status, and whether the case was reviewed by a CDS. In this example, patient identifier information has been deleted. The spreadsheet was submitted by Vicki Davis of Alamance Regional Medical Center in Burlington, NC.

This policy outlines processes for physician queries. It is provided by Donald A. Butler, Manager of Clinical Documentation at Vidant Medical Center in Greenville NC.

This policy establishes guidelines for inpatient physician queries. It is provided by Donald A. Butler, Manager of Clinical Documentation at Vidant Medical Center in Greenville NC.

This policy establishes the procedure for scanning CDI worksheets. It is provided by Donald A. Butler, Manager of Clinical Documentation at Vidant Medical Center in Greenville NC.

This policy establishes guideline for the CDI program practice and process. It is provided by Donald A. Butler, Manager of Clinical Documentation at Vidant Medical Center in Greenville NC.

This document is a position statement for clinical documentation improvement. It is provided by Donald A. Butler, Manager of Clinical Documentation at Vidant Medical Center in Greenville NC.

This is a policy for clinical documentation improvement compliance practices. It is provided by Donald A. Butler, Manager of Clinical Documentation at Vidant Medical Center in Greenville NC.

Here is an auditing and monitoring presentation courtesy of Donald A. Butler, RN, BSN, Manager of Clinical Documentation at Vidant Medical Center. The 43-page PowerPoint also incldues information about good query processes.

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

Michele D. Johnson RN, BSN, and her team at Wellspan Health in York, PA, created this tool to help them identify and track pertinent medial issues as it affects the patients' working length of stay against the typical length of stay assigned to a given DRG. Read more about her team's efforts on the ACDIS Blog.

Ronna Mahlen composed this simple, five-question, CDI specialist query audit that your team can use to conduct regular peer reviews or self audits. She originally shared her tool on CDI Talk.

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.

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."

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.

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.

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.

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.

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.

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.

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

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.

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

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

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.

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.

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

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.

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

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.

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.

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.

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.

Use this sample to review your clinical documentation.

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

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

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.

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

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.

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

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

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

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

Attached is a sample clinical documentation specialist job description.

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.

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.

Clinical documentation manager job description

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