A patient’s medical record contains a wealth of information about his or her hospital encounter, including diagnoses, treatments, operative reports, and ancillary notes. Unfortunately, much of the detailed information found in a patient record is...Read More »
I’m an old (and I do mean OLD) ICU nurse. As a working nurse, my relationships with physicians usually centered on getting them to listen to my assessments: Yes, you need to get out of bed and come see this patient who has stopped...Read More »
The length of stay (LOS) for coronary artery bypass graft patients and valve replacement patients at York Hospital (YH)/ Wellspan Health was significantly higher than the Medicare geometric mean length of stay (GMLOS) according to results of a record...Read More »
Q:I was wondering what supporting evidence there is for the recommendation to go ahead and link hypertension (HTN) with heart failure as a combination code? The Official Guideline for Coding and Reporting as well as Coding Clinic for ICD-9-CM seems to...Read More »
Historically, the limitations of the traditional paper health record have made data extrapolation a difficult, time-consuming process. Deciphering handwriting and digging through volumes of information after discharge was an inefficient and error filled process...Read More »
I have a question for all of the CDI professionals who feel they have achieved a genuine level of expertise (be it after two, three, or even five years): What do you consider as avenues for continued professional advancement, satisfaction, and development...Read More »
