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Forms and Tools Library
Download and use these tested tools and forms developed by your clinical documentation improvement colleagues.
If you have a helpful documentation improvement tool, policy, or form that you would like to submit to the Association of Clinical Documentation Improvement Specialists (ACDIS), please e-mail ACDIS Director Brian Murphy.
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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Present on Admission (POA) query form
Attached is a sample present on admission (POA) query form provided by Janet O’Dell, RN, HIM, CDS, of Morton Plant Mease Countryside and NorthBay hospitals.
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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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Complication coding guidelines
This attached document provides sample policy guidelines for coding complications.
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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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POA exempt list
The attached form includes categories and codes exempt from the Present on Admission (POA) requirement.
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Coding diagnosis clarification sheet
Attached is a sample coding diagnosis clarification sheet.
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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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Key to sample clinical documentation improvement chart
This document, provided by Wendy De Vreugd, senior director of case management, west group, for Kindred Healthcare, provides an explanation of the sample clinical documentation improvement spreadsheet above.
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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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Alphabetized list of 2008 complications/comorbidities (CCs)
Following is a complete 2008 complication/comorbidity list.
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Alphabetized list of 2008 major complications/comorbidities (MCCs)
Following is a complete 2008 major complication/comorbidity list, arranged alphabetically.
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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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MS-DRGs: List of CCs and MCCs
This document provides a complete listing of all the complications/comorbidities (CCs) and major complications/comorbidities under the new Medicare Severity DRG system. It is broken out by ICD-9 and V code and includes a list of all the previous CCs under the former CMS-DRG system.
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Malnutrition query form
The attached sample query form is designed to help physicians better document a patient’s degree of malnutrition.
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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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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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The Present on Admission Training Handbook
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The pressure is on for hospitals to accurately report present on admission (POA) data to avoid Medicare denials. Take a proactive approach to POA indicators by educating coders, and physicians about POA reporting and documentation requirements. Get your POA questions answered and with this easy-to-use handbook that explains what coders and clinicians need to know about POA using clinical scenario examples
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ACDIS members receive a 20% discount on this product. To receive your discount either login or become a member. Or you can buy this product now.
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