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Clinical Documentation Improvement Tips | 2013 | July

Clinical Documentation Improvement Tips

Tips for Improving Your CDI

Working from a Closet is NOT such a Good Idea!

by Kelli Estes, RN, CCDS on

As the EMR (electronic medical record) makes its way into more and more hospitals, the challenge for CDSs (clinical documentation specialists) staying engaged with the medical staff is certainly on the rise. What we are seeing in hospitals with a full EMR is the tendency of CDSs to navigate toward a “closet” space to review […]

Hypotension vs Shock

by Randy Wagner, BSN, RN, CCS on

67 y.o. male was admitted with a hip fracture and it was decided to do a hip replacement. Intra-operatively the femur bled and the patient lost about 1000 ml of blood. Overnight the patient’s blood pressure, baseline 130s/90s, dropped to 80s/40’s. Heart rate, baseline high 60s & low 70s, increased to 90s & 100s. Hgb […]

Previous Encounters

by Kelli Estes, RN, CCDS on

Using previous encounters to glean helpful information when clarifying patient conditions is often misunderstood. Some CDSs are of the mindset any information from a prior encounter is off limits when trying to clarify conditions in a current stay. I suspect this line of thinking has been established from the following AHIMA practice brief. Managing an […]

CO2 Narcosis

by Randy Wagner, BSN, RN, CCS on

Question: Patient was intubated and moved to ICU yesterday. Diagnosis in the note “ventilator dependent rest. Failure secondary to acute COPD exacerbation and altered mental status secondary to CO2 narcosis”. Am I correct in thinking that he would still need to say acute for the respiratory failure? Answer: Yes, Clarify if the patient was in […]

Capturing Nutritional Issues Initiative: A Collaborative Effort

by Cesar Limjoco, MD on

In the past, Clinical Documentation Specialists (CDS) would ask the provider if the patient had nutritional issues based on evidence in the history, physical exam findings and lab results. They would rely on history of weight loss, findings of emaciation and body wasting, BMI, protein, albumin to ask the provider if the patient had malnutrition […]

Case of Late Stage Non-Alcoholic Cirrhosis

by Randy Wagner, BSN, RN, CCS on

Emergency Deptartment impression states “Altered mental Status.” H&P states that upon exam the patient was “foggy”. Lab data shows ammonia level to be elevated. After treatment the ammonia level markedly decreased and the patient’s mental status returned to baseline. The CDS should clarify if “altered mental status” and “foggy” were indicators for Encephalopathy and if […]

Working in Silos is Never a Good Idea

by Randy Wagner, BSN, RN, CCS on

The hospital has an electronic medical record system.  Management of the clinical documentation team originally decided to send physician clarifications via email.  The response rate from the physicians was poor.  CDS management decided to meet with the physicians and get their opinions as to how to send clarifications.  The physicians suggested using the message center […]

Acute Respiratory Failure

by Timothy Shulte, MD on

Appropriate use of the term “acute respiratory failure” has become a hot topic recently. Some well-meaning CDSs, billers and doctors have fallen into the trap of using the term in order to bill at a higher level. This is an especially timely topic with the advent of Value Based Purchasing. At a recent client site, […]

How to Phrase a Good Clarification

by Timothy Shulte, MD on

One of the more difficult tasks for a CDS to master is how to phrase a good clarification. Throughout my career I have often been given the responsibility of evaluating those clarifications. Some have been excellent, some mediocre, and some poor. They have all been instructive and useful. I have collected some examples from each […]