Handbook offers education and clinical support for staff

It took more than 100 hours and four-plus months to create the 60-plus page UNC Healthcare Clinical Documentation: Handbook for Physicians and other Licensed Healthcare Providers, recently donated to the ACDIS Forms & Tools Library (www.acdis.org).

In it, the Chapel Hill, N.C.–based CDI team explores the importance of CDI programs, outlines physician query basics and general documentation guidelines, and discusses top documentation concerns by diagnosis, including encephalopathy, pneumonia, sepsis, anemia, and dementia, among others. It includes information about ICD-10 implementation, explains CC/MCC concepts, and offers examples of good documentation habits.