The attached PDF document contains common documentation improvement target areas as well as "Golden Rules" for physician documentation. Created by ACDIS Advisory Board member Timothy N. Brundage, MD, the two page document includes clinical definitions and documentation reminders for physicians....
“Documentation can be greatly improved by a properly functioning query process,” AHIMA says in its 2008 “Managing an Effective Query Process”...Read More »
Tiffany H. Estes, RHIA, CCDS, CDI Supervisor for UNC Healthcare in Chapel Hill, N.C., donated this 60-plus page UNC Healthcare Clinical Documentation: Handbook for Physicians and other Licensed Healthcare Providers, which took her team more than 100 hours to create....
In a recent “CDI Talk” discussion, ACDIS members shared reporting structure details,describing the pros and cons of their situations. Of those...Read More »
This sample was reviewed and approved by the ACDIS Resource Library Committee in 2023. The committee noted that, though this template would be useful for those just starting out in mortality reviews, it would also require customized columns (ex. columns containing quality reviews) to reflect...
