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Clinical Documentation Improvement Tips | 2013 | September
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Clinical Documentation Improvement Tips. Tips for Improving Your CDI. Monthly Archives: September 2013. Excessive Note Taking = Less Reviews = Decreased Productivity. By Kelli Estes, RN, CCDS on. CDI Review Notes How much is too much? Compiling a CDI version of the documented H & P is too much! Inevitably, CDSs need to make notes to prompt their thoughts about the cases they review, but there is much better use of time and productivity by honing in on what lacks in documentation […]. DCBA tv Episode 1.
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Clinical Documentation Improvement Tips | Excessive Note Taking = Less Reviews = Decreased Productivity
http://cditips.com/excessive-note-taking-less-reviews-decreased-productivity
Clinical Documentation Improvement Tips. Tips for Improving Your CDI. Excessive Note Taking = Less Reviews = Decreased Productivity. By Kelli Estes, RN, CCDS on. CDI Review Notes How much is too much? Compiling a CDI version of the documented H & P is too much! Inevitably, CDSs need to make notes to prompt their thoughts about the cases they review, but there is much better use of time and productivity by honing in on what lacks in documentation rather than copying what is already well stated. Additional...
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Clinical Documentation Improvement Tips | 2013 | August
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Clinical Documentation Improvement Tips. Tips for Improving Your CDI. Monthly Archives: August 2013. R & R Sometimes it’s necessary! By Kelli Estes, RN, CCDS on. Get a CDI Checkup from DCBA. ICD-10 Insights Episode 1. DCBA tv Episode 1. ICD-10 Insights Episode 2. DCBA tv Episode 2. By Clinical Documentation Improvement Tips. 2016 / proudly powered by WordPress. Theme: neni by pixxels.at.
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Clinical Documentation Improvement Tips | Working in Silos is Never a Good Idea
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Clinical Documentation Improvement Tips. Tips for Improving Your CDI. Working in Silos is Never a Good Idea. By Randy Wagner, BSN, RN, CCS on. So, working with the physicians to determine the best process for clarifications will result in an improved response rate. Randy Wagner, BSN, RN, CCS. Http:/ www.dcbainc.com/inside-dcba/#randyw. 4611 Brierwood Place; Atlanta, GA 30360. Get a CDI Checkup from DCBA. ICD-10 Insights Episode 1. DCBA tv Episode 1. ICD-10 Insights Episode 2. DCBA tv Episode 2.
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Clinical Documentation Improvement Tips | Case of Late Stage Non-Alcoholic Cirrhosis
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Clinical Documentation Improvement Tips. Tips for Improving Your CDI. Case of Late Stage Non-Alcoholic Cirrhosis. By Randy Wagner, BSN, RN, CCS on. Emergency Deptartment impression states Altered mental Status. H&P states that upon exam the patient was foggy . Lab data shows ammonia level to be elevated. After treatment the ammonia level markedly decreased and the patient’s mental status returned to baseline. Get a CDI Checkup from DCBA. ICD-10 Insights Episode 1. DCBA tv Episode 1. DCBA tv Episode 2.
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Clinical Documentation Improvement Tips | 2013 | July
http://cditips.com/2013/07
Clinical Documentation Improvement Tips. Tips for Improving Your CDI. Monthly Archives: July 2013. Working from a Closet is NOT such a Good Idea! By Kelli Estes, RN, CCDS on. By Randy Wagner, BSN, RN, CCS on. By Kelli Estes, RN, CCDS on. Using previous encounters to glean helpful information when clarifying patient conditions is often misunderstood. Some CDSs are of the mindset any information from a prior encounter is off limits when trying to clarify conditions in a current stay. I suspect this...Quest...
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Clinical Documentation Improvement Tips | Hypotension vs Shock
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Clinical Documentation Improvement Tips. Tips for Improving Your CDI. By Randy Wagner, BSN, RN, CCS on. 67 yo male was admitted with a hip fracture and it was decided to do a hip replacement. Intra-operatively the femur bled and the patient lost about 1000 ml of blood. Overnight the patient’s blood pressure, baseline 130s/90s, dropped to 80s/40’s. Heart rate, baseline high 60s & low 70s, increased to 90s & 100s. Hgb on admission was 14 which dropped to 8.2 post-op. Randy Wagner, BSN, RN, CCS.
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Clinical Documentation Improvement Tips | Working from a Closet is NOT such a Good Idea!
http://cditips.com/working-from-a-closet-is-not-such-a-good-idea
Clinical Documentation Improvement Tips. Tips for Improving Your CDI. Working from a Closet is NOT such a Good Idea! By Kelli Estes, RN, CCDS on. As the EMR (electronic medical record) makes its way into more and more hospitals, the challenge for CDSs (clinical documentation specialists) staying engaged with the medical staff is certainly on the rise. What we are seeing in hospitals with a full EMR is the tendency of CDSs to navigate toward a closet space to review inpatient records. Verbal clarification...
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Clinical Documentation Improvement Tips | Capturing Nutritional Issues Initiative: A Collaborative Effort
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Clinical Documentation Improvement Tips. Tips for Improving Your CDI. Capturing Nutritional Issues Initiative: A Collaborative Effort. By Cesar Limjoco, MD on. Since the dietitians are not able to cover all patients that are admitted to acute inpatient care, they need a good referral system from all the stakeholders. The floor nurse fills out a nutritional screening form for all patients admitted to inpatient care. CDS, Wound Care RNs, PT and Pharmacy can also refer patients directly to dietitians. It ta...
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Clinical Documentation Improvement Tips | CO2 Narcosis
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Clinical Documentation Improvement Tips. Tips for Improving Your CDI. By Randy Wagner, BSN, RN, CCS on. Patient was intubated and moved to ICU yesterday. Diagnosis in the note ventilator dependent rest. Failure secondary to acute COPD exacerbation and altered mental status secondary to CO2 narcosis . Am I correct in thinking that he would still need to say acute for the respiratory failure? Randy Wagner, BSN, RN, CCS. Http:/ www.dcbainc.com/inside-dcba/#randyw. 4611 Brierwood Place; Atlanta, GA 30360.
