For Physicians
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Clinical Documentation Improvement

Understanding Coding
and Querying
Understanding Coding
Timely Query Response
Queries
Answering Electronic Queries
Documentation Tips
Abbreviations
Acute Blood Loss Anemia
Alcohol Myopathy
Atherosclerosis
Beta Blockers
BMI and Morbid Obesity
BMI
Cerebral Hemorrhage and Tumor
Chronic Heart Failure ACEI ARB for LVSD
Cor Pulmonale
Critical Illness Myopathy
Debridement
Diabetes
Encephalopathy
Functional Quadriplegia
Hypertension
Laterality
MI
Morbid Obesity
Neuro Checks
Pneumonia
Post-op Ileus: Expected or extended?
Respiratory Failure
Sepsis Syndrome
Shock
SIRS/Sepsis
Symbols
Clinical Documentation Improvement assists physicians with accurate and complete documentation in order to better reflect the care patients receive. Complete documentation directly impacts hospitals’ and physicians’:
• Severity of Illness (SOI)
• Risk of Mortality (ROM)
• Insurance reimbursement
• Quality data

Clinical Documentation Specialists are nurses who review charts CONCURRENTLY (while the patient is in house) for proper documentation. We have expanded in the last 6 months with a goal of reviewing all:
• Adult inpatient records, excluding Behavioral Health
• Pediatrics/PICU records
• Women and Infants’ Center records
• Special Care Nursery records

CDI also RETROSPECTIVELY (after discharge) reviews the charts of every patient who expires in the hospital.

The CDI Team will be instrumental in the implementation of ICD-10 . Measures we will be involved in to
prepare physicians for ICD-10 include:

• Assessing current documentation to determine where increased specificity will be required with ICD-10, or if physicians are already documenting with enough specificity.
• Querying physicians for added specificity
• Developing specialty-specific educational materials to assist physicians in better understanding documentation requirements (newsletters, tip sheets, etc.)
• Assisting with the build of documentation templates for quicker/simpler documentation

If you have questions or would like more information:
In Flagstaff, you can call the Clinical Documentation Improvement Help Line at 928-214-2940, or ext. 12940. In Verde, call 928 639-6294, or ext. 36294.