There has been much debate about where CDI belongs in a hospital and to whom it should report. Many advocate a direct chain reporting to Health Information Management (HIM), which seems to be a natural fit, given that CDI specialists spend much of their time clarifying principal and secondary...Read More »
University of South Alabama (USA) Health System’s Children’s & Women’s Hospital in Mobile planned to begin dual CDI/coding of ICD-10-CM in April. Then came the congressionally mandated implementation delay. Now USA’s dual coding won’t take place until later this fall at the earliest, since...Read More »
Of the 187 physicians who responded to a recent survey, only 25% were involved in evaluating or implementing new clinical documentation technologies at their organization. However, when asked how important they considered being involved, 70% said extremely important and 27% said very important...Read More »
I have found that a healthy skepticism needs to be applied within the realm of clinical documentation integrity. In fact, I am thinking of hanging “Caveat Emptor” (Latin for “buyer beware”) sign over my desk! Read More »
Too often an abnormality is an incidental finding, or a lab error and the clinical circumstances, do not support a diagnosis based on that number. Acute hypoxemic respiratory failure can be one of these situations.Read More »
Careful use of terminology may help alleviate miscommunication in situations of potential tragedy. Following the recent death of 33-year-old Marlise Muñoz, who was declared brain dead at a Fort Worth hospital, facilities may want to take the opportunity to review their internal guidelines for...Read More »
Q: We recently admitted a 52-year-old man who was waiting for a liver transplant. He has a history of hepatitis C, chronic back pain, and drug and alcohol abuse. He was found unresponsive at home in a pool of vomit. The toxicology screen on admission was positive for benzodiazepine,...Read More »
