Health Information Management

Tools: Kidney disease query forms

CDI Strategies, March 18, 2010

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Like many CDI specialists, Janice Davis, RN, clinical documentation analyst at High Point (NC) Regional Health System and her four co-workers struggled with obtaining appropriate documentation for chronic kidney disease (CKD) and acute renal failure (ARF).
“The MD’s are consistently documenting renal insufficiency,” says Davis. Often, the physician admitted the patient due to dehydration or other acute illness with no history of kidney disease. The documentation shows the patient may have had an abnormal renal function test upon admission which resolved during his or her stay, Davis adds, but still the physicians do not provide adequate documentation.
“So we decided if we listed the definitions for each, the physicians might be more willing to document appropriately,” Davis says.
Davis shared her documentation clarification forms with ACDIS members and they are available for download in the Forms & Tools section.
Editor’s note: There are a number of kidney disease related materials available for ACDIS members to download in the Forms & Tools section of the Web site, including a sample physician newsletter, a documentation clarification form indicating the stages of renal failure, and the PowerPoint presentation Renal disease present by Robert S. Gold, MD, at the 2009 ACDIS conference. To find a variety of tools on a specific topic, press the Control button and the letter F on your keyboard and type the keywords into the search box.

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