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....

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....

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