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 »
December Douglas, RN, CCDS, is a clinical documentation integrity specialist at Memorial Hermann Hospital, Texas Medical Center, in Houston, Texas.Read More »
Follow these steps to keep your verbal interactions brief and to respect not only the physician’s limited time but also his or her knowledge of the patient’s condition.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 »
Darla Martin, RHIA, CCS, CCDS, is a clinical program manager at Iodine Software. She is a member of the North Carolina and South Carolina ACDIS local chapters, a member of AHIMA and PAHIMA, and is a volunteer member of the ACDIS Forms & Tools Library Committee.Read More »
Jera Van Damme, BSN, RN, CCDS, is a senior clinical documentation educator at Essentia Health in Duluth, Minnesota, a member of the Minnesota ACDIS Chapter, and a member of the ACDIS Forms & Tools Library Committee.Read More »
By Laurie L. Prescott, MSN, RN, CCDS, CDIP, CRC, and Sharme Brodie, RN, CCDS
What do physicians need to learn about CDI? Just about everything—up to a point. If you are joining a new CDI program, physicians likely need to learn what a CDI program is, how it functions, and how it...Read More »
