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Displaying records 1 to 20 out of 3042 results for "Crna documentation".
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SORT RESULTS BY: RELEVANCY | PUBLICATION DATE
By Jennifer Thew, RN Betty Jo Rocchio, MS, BSN, CRNA, CENP,
OCTOBER 8, 2019
NURSING DEPARTMENT
Documentation Documentation
  Documentation standards
JANUARY 1, 2015
LONG-TERM CARE DEPARTMENT
  Documentation terminology that will not support the Medicare claim
  Q&A: Documentation for body mass index
  Skilled Services: How to document for proper reimbursement
OCTOBER 9, 2015
LONG-TERM CARE DEPARTMENT
  A tool for your CNAs to help with accurate ADL documentation
  CMS issues guidance for handling insufficient documentation, ADRs
  Key documentation criteria for supporting the Medicare claim
SEPTEMBER 21, 2018
LONG-TERM CARE DEPARTMENT
  Featured member resource: ADR appeal documentation checklist
NOVEMBER 16, 2018
LONG-TERM CARE DEPARTMENT
Documentation of terminal illness at admission and during the hospice service period must be deta
Documentation of terminal illness at admission and during the hospice service period must be det
To accurately interpret and code physician documentation, the HIM department should employ
JUNE 4, 2014
JUSTCODING
Can the plan of care serve as a way to document medications?  
In addition to documentation by physicians, nurses’ documentation affects patient safety,
JANUARY 8, 2020
NURSING DEPARTMENT
What documentation is necessary for a medication review? The regulation
 Documentation
Using a streamlined approach to EHR documentation may help reduce stress for resident, according
AUGUST 7, 2015
RESIDENCY DEPARTMENT
Residents are a little-utilized but critical link in the documentation chain that drives hospital
JULY 7, 2017
RESIDENCY DEPARTMENT
ACDIS, the Association of Clinical Documentation Impro
APRIL 7, 2011
Effective documentation of the condition and the patients’ co-morbidities may help lawyers
In December 2014, CMS posted a document on its Advisory Panel on Hospital Outpatient Payme
Residents are a little-utilized but critical link in the documentation chain that drives
JULY 14, 2017
RESIDENCY DEPARTMENT
Incomplete documentation in patient clinical records can cause your organization legal and settle
SEPTEMBER 18, 2019
NURSING DEPARTMENT
Physicians who provide E/M services must document the necessary clinical information to support t
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
JANUARY 19, 2016
Medical staffs across the country are discovering their governance documents are inadequate for t
The Association of Clinical Documentation Improvement Specialists (ACDIS), the premier healthcar
SEPTEMBER 10, 2012
  A Comprehensive Error Rate Testing (CERT) study found insufficient documentation
JULY 22, 2015
JUSTCODING
Now in its second edition, documentation-improv
APRIL 9, 2014
JUSTCODING
Now in its second edition, documentation-improv
JUNE 4, 2014
JUSTCODING
Now in its second edition, documentation-improv
AUGUST 13, 2014
JUSTCODING
Become more proactive. You no longer can wait for face-to-face documentation to arrive within sev
 Although documentation matters more and more in today?s world of ever-changing regulations, med
AUGUST 4, 2017
RESIDENCY DEPARTMENT
Agencies need to begin now to ensure that they are getting valid face-to-face documentation with the
Q: I’m in a little debate: Does documentation of the patient’s body mass in
MAY 7, 2014
JUSTCODING
Q: Can you code strictly from emergency room (ER) documentation? Can you code from test re
  Why are physician queries so critical to accurate documentation and coding? The an
The Association of Clinical Documentation Improvement Specialists (ACDIS) released a new position
NOVEMBER 5, 2014
The first Clinical Documentation Improvement Week is taking place from September
SEPTEMBER 21, 2011
ACDIS, the Association of Clinical Documentation Improvement Specialists, the leading national as
FEBRUARY 8, 2011
Providers don’t often receive education on clinical documentation, which can be a challenge
With the transition to ICD-10, some documentation issues have required the capture of new inform
With the transition to ICD-10, some documentation issues have required the capture of new informa
In a recent frequently asked questions (FAQ) document released by the Centers for Medicare &
Q&A: Managing LS, EC, and EM documentation Editor
DECEMBER 20, 2016
ACCREDITATION DEPARTMENT
Q: Can you code strictly from emergency department (ED) documentation? Can you code from tes
DECEMBER 16, 2015
JUSTCODING
Correct, complete documentation is the foundation of a sound medical record and compliant reimbu
JUNE 15, 2018
RESIDENCY DEPARTMENT
The Association of Clinical Documentation Improvement Specialists (ACDIS) last week updated its
OCTOBER 13, 2015
We all know that ICD-10 codes will require more complete documentation. We’ve been t
An outpatient clinical documentation improvement (CDI) program should be aligned with a fa
Proper documentation is critical when it comes to supporting medical necessity and providing qual
Q: What are some tips when evaluating our documentation system?
What should our clinicians document if the patient hasn't had the flu vaccine yet? The pa
Is it true that the following documentation is an improper certification statement on our
There has been a fair amount of coverage on the documentation requirements needed to assign ICD-1
The focus for clinical documentation improvement (CDI) specialists has historically been on the i
FEBRUARY 21, 2017
PHYSICIAN PRACTICE DEPARTMENT
by Kirsten Dize Make completing documentation in the home a requirement for all
  Medical staffs are discovering their governance documents are inadequate for tod
SEPTEMBER 18, 2014
MEDICAL STAFF DEPARTMENT
ICD-10-CM simplifies coding for sepsis provided the physician completely and accurately documents
NOVEMBER 18, 2015
JUSTCODING
Insufficient documentation led to approximately 97% of improper payments for kyphoplasty a
JULY 23, 2014
JUSTCODING
Q: If the physician documents “concerning for,” “considering,” “
AUGUST 12, 2015
JUSTCODING
HCPro, Inc., and ACDIS, the Association of Clinical Documentation Improvement Specialists, today
JUNE 15, 2011
Take a close look at the documentation guidelines that CMS suggests for the practice improvement
by Kirsten Dize Strong documentation is key in home health, and implementation o
Q: Our physicians document a diagnoses of pneumonia but do not normally make a specific
APRIL 9, 2014
JUSTCODING
Measure a wound from inside edge to inside edge to correctly document wound size, and ensure that
We have been told that the following documentation would position us for a potential clai
Clinical documentation improvement (CDI) programs need to expand their focus beyond CC/MCC capt
DECEMBER 2, 2015
JUSTCODING
What pitfalls can you avoid to ensure proper documentation? These are eight common mistakes made:
JANUARY 28, 2020
NURSING DEPARTMENT
By utilizing the information documented in the record, coders can report the BMI from a dietitian
The documentation surrounding your QAPI program should include:  
MAY 21, 2014
JUSTCODING
Q: Is the statement “please document in a progress note to capture the severity of i
Q: In terms of coding blood transfusions, does the documentation of which intravenous (IV) s
NOVEMBER 18, 2015
JUSTCODING
Clinical documentation is often overlooked during residency, yet without proper training, new ph
SEPTEMBER 9, 2016
RESIDENCY DEPARTMENT
ACDIS, the Association of Clinical Documentation Improvement Specialists
AUGUST 1, 2012
In recent years, hospitals have increasingly focused on creating clinical documentation improveme
New EP: Avoid RFIs by keeping documents and service manuals in library “If it was
JANUARY 1, 2018
SAFETY DEPARTMENT
New EP: Avoid RFIs by keeping documents and service manuals in library “If it was
DECEMBER 1, 2017
ACCREDITATION DEPARTMENT
Documentation: Getting the details right Joint Commission eli
DECEMBER 6, 2016
ACCREDITATION DEPARTMENT
The electronic document management system (EDMS) plays a role in designing the official legal h
Clinical documentation improvement (CDI) specialists and case managers share a common goal but of
Nurses new to home health struggle with the completion of documentation related to patient care.
CMS doesn't require Medicare Advantage plans to have a face-to-face document for home health. Bu
No. The regulations do not mandate any particular form or format for documentation or confirmati
Q: Can you clarify the expectations related to documenting the discussion betwee
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s pre
FEBRUARY 16, 2015
The Association of Clinical Documentation Improvement Specialists (ACDIS) honored the nation&rsqu
MAY 25, 2016
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
FEBRUARY 9, 2015
OCTOBER 8, 2014
JUSTCODING
APRIL 23, 2014
JUSTCODING
Documentation will be important to support supply utilization and payment. Claims
Regardless of the clinical background of those responsible for reviewing documentation, it can be
It’s an age-old question: How do you get physicians to support documentation improvement ef
Correct, complete documentation is the foundation of a sound medical record and compliant reimbur
JUNE 15, 2018
RESIDENCY DEPARTMENT
Documentation example for coders in
OCTOBER 29, 2014
JUSTCODING
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician document
  Q: Is it okay to code a diagnosis if the physician documents two diagnoses usin
SEPTEMBER 24, 2014
JUSTCODING
By James S. Kennedy, MD, CCS, CDIP The physician documented “encephalopathy&
MARCH 25, 2015
JUSTCODING
Documentation example in
MARCH 4, 2015
JUSTCODING
The Certified Clinical Documentation Specialist (CCDS) exam hit a pretty big milestone last weeke
If you feel pretty confident as an agency that your documentation can pass muster and the totalit
MARCH 11, 2015
JUSTCODING
JULY 22, 2015
JUSTCODING
"[A]s we enter into clinical practice, physicians face the burdens of documentation and reg
SEPTEMBER 17, 2015
MEDICAL STAFF DEPARTMENT
In the early days of clinical documentation improvement programs many staff members reported up t
Q: Can you tell me whether there is a resource that lists documents and required retentio
The patient care plan (485) is not a stand-alone documentation system; it is the legal record of
Residency training typically serves as physicians’ first exposure to the clinical document
AUGUST 11, 2017
RESIDENCY DEPARTMENT
Documenting medical necessity has become a big topic over the last several years and there has be
MARCH 22, 2019
LONG-TERM CARE DEPARTMENT
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
DECEMBER 30, 2015
Finding effective ways to continuously remind physicians of documentation improvement methods can
Focus on documentation. CMS believes it is the responsibility of the homecare provider to attempt
ACDIS—the Association of Clinical Documentation Improvement Specialists—announced tod
MARCH 18, 2014
NOVEMBER 20, 2013
JUSTCODING
A patient comes into the ED following an automobile accident. The physician documents that the pa
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician document
SEPTEMBER 3, 2014
JUSTCODING
SEPTEMBER 3, 2014
JUSTCODING
Clinical documentation improvement (CDI) programs need to expand their focus beyond CC/MCC captur
I am searching for clear, legitimate, documented guidance regarding coding for a verbal o
by: Josh Poltilove Conduct a quality audit of documentation your therapists submi
by: Kirsten Dize CMS’ revised OASIS Q&A document offers welcome insight
APRIL 9, 2014
JUSTCODING
A patient presents to the ED with a headache, nausea, and vomiting. The physician documented that
FEBRUARY 25, 2015
JUSTCODING
OCTOBER 8, 2014
JUSTCODING
Although documentation matters more and more in today’s world of ever-changing regulations,
AUGUST 4, 2017
RESIDENCY DEPARTMENT
Q: Is it okay to code a diagnosis if the physician documents two diagnoses using
ACDIS is proud to celebrate the 3,000th Certified Clinical Documentation Specialist (CCDS) creden
Q: When physicians continue to only document respiratory failure in the inpatien
JUNE 4, 2014
JUSTCODING
NOVEMBER 20, 2013
JUSTCODING
The Medicare Payment Advisory Commission's documents/Mar14Entire
MARCH 21, 2014
LONG-TERM CARE DEPARTMENT
In the budget document released by the Office of Management and Budget, the White House's propose
Friday, April 11 is the deadline to apply for the Certified Clinical Documentation Specia
AUGUST 12, 2015
JUSTCODING
AUGUST 26, 2015
JUSTCODING
Q: I have seen documentation of oliguric renal failure and non-oliguric renal failure. What is th
OCTOBER 21, 2015
JUSTCODING
OCTOBER 14, 2015
JUSTCODING
Q: I have seen documentation of oliguric renal failure and non-oliguric renal failure. Wha
 It will depend a lot on documentation. This may be something to query. For example, even if
The Association of Clinical Documentation Improvement Specialists (ACDIS) just launched a redesig
JUNE 20, 2016
The Association of Clinical Documentation Improvement Sp
OCTOBER 1, 2010
The Association of Clinical Documentation Improvement Specialists (
FEBRUARY 23, 2012
HCPro, Inc. and the Association of Clinical Documentation Improvem
Does your hospital have a clinical documentation improvement (CDI) program (i.e., a department, s
APRIL 23, 2014
JUSTCODING
Does your hospital have a clinical documentation improvement (CDI) program (i.e., a department, s
APRIL 30, 2014
JUSTCODING
MAY 14, 2014
JUSTCODING
New on JustCoding Platinum! New ICD-10-CM documentation examples in
JULY 9, 2014
JUSTCODING
Every provider has basic information he or she must document in the health record, says Lisa Ging
Take an in-depth look at coding, documentation, and querying for acute kidney injury (AKI). Durin
APRIL 8, 2015
JUSTCODING
Take an in-depth look at coding, documentation, and querying for acute kidney injury (AKI). Durin
MARCH 25, 2015
JUSTCODING
FEBRUARY 11, 2015
JUSTCODING
Incidents reports are a pain to fill out, but vital for documenting what happened and for pro
SEPTEMBER 3, 2015
NURSING DEPARTMENT
Advancements in electronic health records (EHR) have improved nursing documentation and patient s
JANUARY 26, 2017
NURSING DEPARTMENT
The proof of medical necessity strictly relies on the MD documentation and diagnosis and the skil
Many questions have swirled around the issue of medical necessity and how to document it appropri
DECEMBER 1, 2015
CASE MANAGEMENT DEPARTMENT
by Tami Swartz Thoroughly examine clinicians’ documentation &mdash
MAY 6, 2015
JUSTCODING
OCTOBER 22, 2014
JUSTCODING
Q: The primary physician documented subacute cerebral infarction and I am wondering whe
NOVEMBER 5, 2014
JUSTCODING
I’m always excited to read an article about clinical documentation improvement in the mains
A proposed CMS change to the 2017 Medicare Physician Fee Schedule will require surgeons document
SEPTEMBER 13, 2016
ACCREDITATION DEPARTMENT
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
JANUARY 29, 2016
MARCH 19, 2014
JUSTCODING
ACDIS is preparing to draft its third incarnation of the popular The Physician Documentation I
APRIL 23, 2014
JUSTCODING
APRIL 30, 2014
JUSTCODING
MAY 7, 2014
JUSTCODING
JUNE 11, 2014
JUSTCODING
Knowing the bones of the feet, and ensuring they're being properly documented by providers
JULY 30, 2014
JUSTCODING
AUGUST 6, 2014
JUSTCODING
AUGUST 20, 2014
JUSTCODING
AUGUST 27, 2014
JUSTCODING
  Creating a new position to assume a physician’s documentation duties may l
APRIL 15, 2015
JUSTCODING
FEBRUARY 25, 2015
JUSTCODING
Click the PDF icon above to download. Included in this document:
MAY 27, 2015
JUSTCODING
JUNE 24, 2015
JUSTCODING
JULY 15, 2015
JUSTCODING
While many case managers today work closely with clinical documentation improvement (CDI) special
JANUARY 5, 2016
CASE MANAGEMENT DEPARTMENT
On March 8, CMS posted a document in the Federal Register correcting technical and typog
Coding guidelines direct to code all documented conditions that exist at the time of the visit an
MAY 7, 2014
JUSTCODING
Q: We had a question regarding documentation in a record of SIRS due to acute peritonit
MAY 21, 2014
JUSTCODING
Q: In the past few weeks, we noticed physicians are documenting acute conge
Q: If a physician documents sepsis due to decubitus ulcer and UTI due to indwelling catheter, c
Blogs from industry experts in healthcare that keep users up-to-date on the latest happenings in their fields.
AUGUST 20, 2014
JUSTCODING
  When a provider fails to document whether a patient diagnosed with monoplegia ha
MAY 13, 2015
JUSTCODING
JUNE 18, 2014
JUSTCODING
JULY 29, 2015
JUSTCODING
Here are some of the highlights from the document/covid-recomm
AUGUST 27, 2020
SAFETY DEPARTMENT
MARCH 26, 2014
JUSTCODING
MARCH 5, 2014
JUSTCODING
We want physicians to be very clear in their documentation about what’s wrong with the pati
JUNE 10, 2015
JUSTCODING
CMS posted updated versions of all the guidance documents posted on the
MARCH 26, 2014
JUSTCODING
Q: The primary physician documented subacute cerebral infarction and I am wondering whethe
SEPTEMBER 17, 2014
JUSTCODING
Bylaws serve as the governing documents of the medical staff. Bylaws must meet the hospital&rsquo
DECEMBER 13, 2013
MEDICAL STAFF DEPARTMENT
NOVEMBER 20, 2013
JUSTCODING
APRIL 9, 2014
JUSTCODING
APRIL 23, 2014
JUSTCODING
JUNE 4, 2014
JUSTCODING
MAY 28, 2014
JUSTCODING
JULY 9, 2014
JUSTCODING
JULY 16, 2014
JUSTCODING
JULY 23, 2014
JUSTCODING
JULY 30, 2014
JUSTCODING
Does your facility perform outpatient clinical documentation improvement (CDI) reviews?
SEPTEMBER 3, 2014
JUSTCODING
Does your facility perform outpatient clinical documentation improvement (CDI) reviews?
SEPTEMBER 10, 2014
JUSTCODING
SEPTEMBER 24, 2014
JUSTCODING
If the hospital documentation, including history and physical and progress notes, doesn’t s
OCTOBER 22, 2014
JUSTCODING
MARCH 25, 2015
JUSTCODING
Those interested in taking the Certified Clinical Documentation Specialists (CCDS) credential exa
FEBRUARY 11, 2015
JUSTCODING
A January 2015 documents/reports/federal-trade-commissio
FEBRUARY 4, 2015
JUSTCODING
Coders and clinical documentation improvement specialists need a clear understanding of how to us
OCTOBER 7, 2015
INFECTION CONTROL, QUALITY & PATIENT SAFETY DEPARTMENT
Although burnout and stress are well-documented phenomena in healthcare, few interventions have b
OCTOBER 15, 2015
MEDICAL STAFF DEPARTMENT
Does your hospital have an inpatient or outpatient clinical documentation improvement (CDI) progr
DECEMBER 2, 2015
JUSTCODING
ACDIS is making several changes to the Certified Clinical Documentation Specialist exam effective
As of last week, 2,910 people hold the Certified Clinical Documentation Specialist credentia
In 2016, those sitting for the Certified Clinical Documentation Specialist (CCDS) exam face the b
The Association of Clinical Documentation Improvement Specialists (ACDIS) will soon be launching
The Association of Clinical Documentation Improvement Specialists (ACDIS) will soon be launching
The National Resident Matching Program recently published its set of reports documenting how appl
OCTOBER 7, 2016
RESIDENCY DEPARTMENT