Health Information Management

Membership update: Forms & Tools Library items added, revised library forthcoming

CDI Strategies, December 20, 2012

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For more than six months, a number of dedicated volunteers have pored over the the ACDIS Forms & Tools Library. They reviewed:

Items were examined for their adherence to existing guidelines, coding requirements, clinical indicators, and industry best practices. Volunteers made various recommendations at times to move a library item from one shelf to another, to update an item, or to seek clarifications from the item author.
 
Since its inception, ACDIS members have graciously donated their CDI materials to the library; sharing so that others who came after them would not have to labor so long and worriedly. The Forms & Tools Library continues to be one of the most frequently visited sections of the site with more than 31,000 visits in 2012 and remains one of the most popular benefits of ACDIS membership.
 
Internally, our web-solutions group is working to redesign this section so it is more user-friendly. The new pages will have drop-down menus and enhanced search options to allow you to sort documents by name, date, and document type making it easy to find what you are looking for. Please look for additional information regarding these pages in the coming weeks.
 
Furthermore, ACDIS is seeking volunteers for a three-member standing Forms & Tools Library Audit Committee which will meet monthly to offer new library items and to review library donations. To volunteer, email ACDIS Associate Director Melissa Varnavas at mvarnavas@cdiassociation.com.
 
In the meantime, a number of additional materials have been uploaded for ACDIS members to use. These include:
  • Handbook: UNC Healthcare. 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. It explores the importance of CDI programs, outlines physician query basics and general documentation guidelines, and discusses top documentation concerns by diagnosis including encephalopathy, pneumonia, sepsis, anemia, and dementia, among other important items.
  • Newsletter: Monthly highlights. Kim MaGee, RN, the CDI program’s team leader at Park Nicollet Health Services in Minneapolis, Minn., offers this sample facility-specific CDI newsletter. Her team works with its physician advisor to devise a different clinical topic each month and disseminate the newsletters to the physician staff.
  • Brochure: CDI basics for physicians. Karen Macy, RN, CDI specialist at Champlain Valley Physicians Hospital (CVPH) in Plattsburgh, N.Y., offers this sample tri-fold brochure full of need-to-know documentation improvement program basics which she gives to physicians when explaining the role of CDI specialists at her facility. NOTE: This brochure was created using Microsoft Publisher.
  • Poster: Chest pain documentation. Karen Macy, RN, CDI specialist at Champlain Valley Physicians Hospital (CVPH) in Plattsburgh, N.Y., offers this poster regarding documentation requirements related to chest pain.
  • Query: Altered mental status. Cynthia Prayzner at Southcoast Health System in New Bedford, Mass., offers this sample altered mental status query form which asks physicians to identify the chronicity of the diagnosis, providing additional specificity not on the query form but in the medical record's progress note.
  • Query: Cause/effect relationship of diseases. This sample query regarding establishing cause and effect relationships between diagnoses was donated by Paul Evans, RHIA, CCS, CCS-P, CCDS, manager of Regional Clinical Documentation & Coding Integrity, at Sutter Health in San Francisco, Calif.



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