By Howard Rodenberg, MD, MPH, CCDS
When my son was in middle school, I would call him every evening to review the school day. I would want to know all about the things he was learning and the friends he was making, and he would grudgingly oblique me with a one-word answer if he...Read More »
Q: Is it appropriate to query whether a pressure ulcer was present on admission (POA) if it was not documented until later in the admission?Read More »
Q:Our coders are having trouble determining how much clinical evidence to cite in our queries. Is there a general rule for how much to include?Read More »
Along with my CDI work, I’m still pulling a few shifts each month as an ED doc. Having been in “The Pit” for nearly three decades, I’m intimately familiar with the Laws of Emergency Medicine, such as:
By Marion Kruse, BSN, RN, MBA, and Jennifer Cavagnac, CCDS
As medical information moves from paper-based to electronic, CDI professionals as well as providers, hospital clinical and administrative leaders, coders, and other record analysts must consider the following questions...Read More »
Q:We recently had a patient admitted for femur fracture from falling off some bleachers to ground. The patient has a history of osteoporosis and takes medications for this disease. The physician does not state traumatic...Read More »
