Q: I have a number of questions related to strokes, but essentially, can you describe the clinical definitions of stroke and explain what CDI professionals should be looking for in the medical record?Read More »
Kathie McAlexander, RN, CCDS, works at the University of Mississippi Medical Center in Jackson, Mississippi, and has been in the CDI field since 2002.Read More »
Q: If an uncertain diagnosis is only documented by a consultant consistently through the medical record, including in the last progress note, and is left out of the discharge summary, should that diagnosis be coded?Read More »
Suzanne Megown, RN, BSN, CCDS, CDIP, CCS, is a CDI specialist at St. Luke’s Hospital in Chesterfield, Missouri, and a member of the St. Louis ACDIS chapter, AHIMA, the Missouri component of AHIMA, and eHIMA. A CDI specialist for the past nine years, she worked in pain management...Read More »
Q: According to Official Guidelines for Coding and Reporting, uncertain diagnoses should be documented at the time of discharge. If a consultant documents an uncertain diagnosis in the final or last progress note and no discharge...Read More »
Jose M. Gonzalez O’Neill, MSHIM, RHIA, is the vice president of the Florida ACDIS chapter, and HIM service line manager for medical transcription and inpatient coding at a large hospital system in the Orlando area.Read More »
