Q:The majority of the admissions I am reviewing this week are for an elderly population. It seems that they all have the same admitting diagnoses: Failure to thrive (FTT), urinary tract infection (UTI), fever, dehydration, altered mental status (AMS). I am confused...Read More »
Q: Our physicians frequently document ‘meets sepsis criteria.’ Is this a bad habit forming? If the patient is septic, shouldn’t the physician state sepsis due to, or just sepsis? I worry that if the patient has a few vital signs off the physicians are documenting sepsis...Read More »
Q: I attended the ACDIS conference in Nashville. (It was excellent!) I had a question about whether or not queries can be used to question the documentation of a condition or procedure where the clinical picture in the record does not appear to support a given diagnosis. I thought the...Read More »
Q:I have come across an ethical dilemma. We have a small CDI program and a “home grown” application we use to report metrics to the chief financial officer (CFO). In this, we track whether a CDI specialist’s query captured a CC/MCC. If it is the first and/or only CC/MCC...Read More »
Q:I am concerned about the way we are being taught to write queries; it feels counter to the way I learned at the CDI Boot Camp and the materials I have read via ACDIS. For example, the query lists the appropriate clinical indicators from the record which would support...Read More »
Q: Can you clarify the requirements surrounding the use of E codes? We have been working on documentation concerns related to patient safety indicator (PSI) 15 and wonder if E codes are really required to be reported or not. Can a facility simply decide to use on not to use them...Read More »
