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Forms and Tools Library

Download and use these tested tools and forms developed by your clinical documentation improvement colleagues. To locate a specific form press the Control button and the letter F on your keyboard and type the keywords into the search box.

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 or Associate Director Melissa Varnavas.



2010 CC/MCC lists and CC/MCC additions and deletions

The attached excel document, provided by ACDIS member Theresa Davis, RN, CCDS, is a complete sortable list of the FY 2010 CC and MCC lists, as well as the CC and MCC additions and deletions. These can be found in the tabs across the bottom of the page.



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FY 2010 CC list

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



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FY 2010 MCC list

Attached is the fiscal year (FY) 2010 list of Major Complications/Comorbidities (MCCs).



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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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Sample Local Chapter Newsletter

The attached document provides a sample newsletter from the Florida ACDIS Chapter. In it, chapter president Sylvia Hoffman offers some query tips and talks about the group's upcoming events.



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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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Physician Communication Worksheet

Use this form to document CDI professionals’ ongoing communications with physicians.



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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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Regional ACDIS Membership Form

ACDIS members who are thinking about starting a regional gathering of like-minded professionals may want to consider using this attached form to learn more about each other. This basic informational form asks meeting attendees for their name and contact information as well as any ideas for potential speaker topics. Feel free to download it and adapt it to your needs.



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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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Alphabetized list of 2009 major complications/comorbidities (MCCs)

Courtesy of Shane Catalano, RN, CDI consultant with DCBA, Inc., attached is a comprehensive list of the 2009 major complications/comorbidities, arranged logically as well as alphabetically for ease of use.



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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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Sample physician documentation tip sheet--New ICD-9-CM fever codes

Attached is a sample physician documentation tip sheet for the new fiscal year 2009 ICD-9-CM fever codes, courtesy of Gloryanne Bryant of Catholic Healthcare West.



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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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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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ACDIS 2nd Annual Conference: Audio Recordings

Always have access to the 2nd Annual Association of Clinical Documentation Improvement Specialists Annual Conference, by adding this valuable resource to your professional library. This set of recordings includes sessions from the 2009 conference.

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.