Health Information Management

Membership update: Queries, tracking tools, tip cards posted to Forms & Tools Library

CDI Strategies, August 1, 2013

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ACDIS members have access to a large collection of sample Forms & Tools donated by their peers. Recent additions include:

  • Query form regarding Multi-System Organ Failure donated by Katy Good, RN, BSN, CCDS, CCS, Clinical Documentation Program Coordinator, AHIMA Approved ICD-10CM/PCS Trainer, of Flagstaff Medical Center in Flagstaff, Ariz.
  • Query form for diagnostic clarification/confirmation of diagnosis donated by Paul Evans, RHIA, CCS, CCS-P, CCDS.
  • ICD-10 query forms addressing common coding and documentation themes associated with the ICD-10 code set adapted from The CDI Specialist’s Guide to ICD-10, created and donated by Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director at HCPro, Inc., in Danvers, Mass.
  • Case examples and sample queries for conditions typically found in pediatric patient populations donated by Karen Bridgeman, MSN, RN, clinical documentation integrity specialist at the Medical University of South Carolina in Charleston, following her ACDIS 2013 National Conference presentation "Leap Frog to Pediatrics: Implementing a Successful Pediatric CDI Program."
  • Query form for malnutrition donated by Joann A. Agin, RHIT, regional manager, data quality at Carondelet Health in Kansas City, Mo.
  • Case examples and related sample queries, as well as a documentation improvement tip card regarding post operative complications donated Audrey G. Howard, RHIA, AHIMA-Approved ICD-10-CM/PCS Trainer, and Cheryl Manchenton, RN, BSN, 3M Consulting, adapted from the 2012 HCPro Inc., audio conference “Inpatient Postoperative Complications: Resolve Your Facility’s Documentation and Coding Concerns.”
  • Physician history and physical documentation improvement tip card donated by Mary Solomon, BSN, RN, CCM, CCDS, CDI specialist at Tahoe Pacific Hospitals in Reno, Nev.
  • Altered mental status documentation improvement tip card in PDF form donated by Paul Evans, RHIA, CCS, CCS-P, CCDS.
  • Ten sample physician documentation improvement newsletters on topics from anemia to stroke donated by ACDIS Advisory Board member Timothy N. Brundage, MD.
  • A patient mortality documentation tool package in zip-file format containing a physician documentation tip sheet, a CDI specialist worksheet, a tracking spreadsheet, and sample procedure, submitted by Vicki Davis, RN, CDI specialist at Alamance Regional Medical Center, Burlington, N.C., who presented on the topic at the 2013 ACDIS National Conference.

Editor’s Note: These forms and tools are provided by individual hospitals as sample documents to be shared among the ACDIS membership. They should be vetted by your facility administration to ensure compliance, and credit should be given to the original author if applicable. To donate an item to the library, contact ACDIS Associate Director Melissa Varnavas.

 



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