As part of the eighth annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Caryn Nowak, RHIA, CDIP, a clinical documentation specialist at Rady Children’s Hospital in San Diego...Read More »
Q: I was originally taught to do subjective, objective, assessment, and plan notes for a prior job with principal diagnosis listed first. Do I need to intervene when providers change the first-listed diagnosis from...Read More »
Rita Fields, BSN, RN, CCDS, recently retired from her role as regional CDI manager at Baptist Health in Louisville, Kentucky, and was named CDI Professional of the Year in 2017. Susanne Warford, MBA-HCM, RN, CCDS, is the system CDI analyst and appeals nurse for Baptist Health in Louisville,...Read More »
Q: I recently was reviewing a chart where the infection control physician stated the patient had sepsis, but the attending listed bacteremia as the diagnosis. I sent a query to clarify which was correct and the attending confirmed bacteremia. On the...Read More »
Autumn Reiter, BSN, RN, CCDS, CDIP, CCS, director of CDI services for TrustHCS, based in Springfield, Missouri, will present “Five Pillars for Building a Successful CDI Program in Emergency Services and Other Outpatient Areas,” on Day 1 of the ACDIS Symposium: Outpatient CDI....Read More »
Q: What do you suggest the providers write to describe medication/substance overdose? In my experience, physicians don’t write “poisoning” in these cases. Read More »
Q: I’ve heard that if a condition cannot be identified as POA, it will not keep the criteria for a principal diagnosis and cannot be sequenced as such. I recently had a patient who was admitted for syncope and all the workup was negative, but it’s...Read More »
