Policy and Procedures

cheryl.rymercheryl.rymer
in CDI Talk Archive
We have recently implemented a new CDI program at my facility. I am pioneering it on my own and would like to thank everyone on here for all the information that you share. It is really helpful to me as I try to create a successful program.

I was wondering if anyone would mind sharing their P&P for CDI?

Comments

  • laura.bohls@prairielakes.comlaura.bohls@prairielakes.com
    edited April 2016
    There are many P&Ps on the tools of ACDIS website


  • vanessa.falkoffvanessa.falkoff
    edited April 2016
    If you send me your address I will share what I have :)

    Vanessa Falkoff, RN
    Clinical Documentation Coordinator
    University Medical Center of Southern Nevada
    office (702) 383-7322
    cell (702) 204-0054
    vanessa.falkoff@umcsn.com



  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited April 2016
    As others have indicated, there are some great examples in the F&T library.
    I've tried to attach 6 samples (removed names, etc.) for what I developed incorporating much of what was in those examples & other sources. Unfortunately, the filter won't let through that many files.

    Email me if anyone is interested. I'll collect email addresses and then send out to a group.
    I've also asked Melissa to see if she would be interested in posting to the F&T library.

    Note -- the query documents are consolidated and apply to both Coding & CDI.

    Topics:
    CDI Compliance
    CDI Position Statement
    CDI Practices Policy
    CDI Worksheet Scanning Procedure
    Physician Query Policy
    Physician Query Procedure


    Don

    Donald A. Butler, RN, BSN
    Manager, Clinical Documentation
    Vidant Medical Center, Greenville NC
    DButler@vidanthealth.com ( mailto:mDButler@vidanthealth.com )


  • bosankorbosankor
    edited April 2016
    Don,
    I would love a copy - bosankor@hss.edu

    Thank you!

    Roberta Bosanko-Cera MS, CCS-P, CPMA, CPC-P, CEMC
    AHIMA ICD-10-CM/PCS Ambassador & Training Instructor
    Director, Finance ICD-10
    Hospital For Special Surgery
    535 E 70th Street
    New York, NY 10021
    bosankor@hss.edu
    212-774-2906 Office

  • sharon.cooper@owensborohealth.orgsharon.cooper@owensborohealth.org
    edited April 2016
    Don,

    I would also be interested in receiving!

    Sharon.cooper@omhs.org

    Thanks!
    Sharon


  • Unknown
    edited April 2016
    Hi Don

    Me too. fantins@trinity-health.org
    Thanks, Susan
    >>> CDI Talk 05/22/2012 12:19 PM >>>
    Don,

    I would also be interested in receiving!

    Sharon.cooper@omhs.org

    Thanks!
    Sharon


  • amy.wickenhauseramy.wickenhauser
    edited April 2016
    Don would you please send me a copy.

    amy.wickenhauser@advocate.heatlh.com


    Thank you,
    Amy Wickenhauser
    Lead Clinical Documentation Specialist
    Advocate BroMenn Medical Center
    Phone: (309) 268-2769 fax: (309) 268-3956
    amy.wickenhauser@advocatehealth.com



  • tmcginn@northshore.orgtmcginn@northshore.org
    I'd love a copy too Don - thank you!

    tmcginn@northshore.org

    Tricia McGinn, MBA, BSN, RN
    Director, Documentation Integrity
    NorthShore University HealthSystem
    4901 Searle Parkway, Suite 330
    Skokie, IL 60067
    Phone: 847-982-4212
    Fax: 847-982-4273
    tmcginn@northshore.org
  • Unknown
    edited April 2016
    Please add me and as so often Don, thank you for your generous spirit with sharing! lthennes@centegra.com

  • vdavis2vdavis2
    edited April 2016
    + ME too!!!!!-V

    Vicki S. Davis, RN CDS
    Clinical Documentation Improvement Manager
    Health Information Management Department
    Alamance Regional Medical Center
    Office (336) 586-3765
    Ascom Mobile (336) 586-4191
    Fax (336) 538-7428
    vdavis2@armc.com

  • tpeytontpeyton
    edited April 2016
    I also tried to email you but got it back. I would also like a copy as well. Thank you in advance.

    Tracy M Peyton RN, CCDS
    Bradford Regional Medical Center
    Upper Allegany Health Systems
    116 Interstate Parkway
    Bradford, PA 16701
    814-558-0406




  • sabullocksabullock
    edited April 2016
    Don,
    I also tried to email you directly and got a bounce back. Please add me to your list.

    sabullock@umc.edu

    Shelia Bullock, RN, BSN, MBA, CCM, CCDS
    Director, Clinical Documentation Services
    University of Mississippi Health Care
    2500 North State Street
    Room S 336
    Jackson, MS 39216
    T: 601-815-3079 F: 601-815-9505
    sabullock@umc.edu
    umhc.com
  • patricia.fountainpatricia.fountain
    edited April 2016
    Hi Don,
    I would likewise be very appreciative to receive this information. Thank you in advance!
    Patti Fountain, BS RN MBA
    Regional Director, Clinical Documentation
    New England Market, Vanguard
    patricia.fountain@stvincenthospital.com/patricia.fountain@mwmc.com
    St. Vincent Hospital
    123 Summer Street
    Worcester, MA 01608
    Office: 508-363-9453
    Cell: 401-419-3449
    Pager: 27207
    [cid:502195820@12082011-1474]

  • patricia.fountainpatricia.fountain
    edited April 2016
    Hi Don,
    I would likewise be very appreciative to receive this information. Thank you in advance!

    Patti Fountain, BS RN MBA
    Regional Director, Clinical Documentation
    New England Market, Vanguard
    patricia.fountain@stvincenthospital.com
    St. Vincent Hospital
    123 Summer Street
    Worcester, MA 01608
    Office: 508-363-9453
    Cell: 401-419-3449
    Pager: 27207
    [cid:502195820@12082011-1474]

    When something can be read without effort, great effort has gone into its writing.
    ~Enrique Jardiel Poncela






  • dsmith12h@aol.comdsmith12h@aol.com
    edited April 2016
    I would like a copy- dsmith12h@aol.com

    Debbie Smith, RN; CCDS
    Certified Clinical Documentation Specialist
    UT Southwestern Medical Center at Dallas
    5909 Harry Hines Blvd.
    Dallas, TX 75390
    214-645-5217


  • cstukenbergcstukenberg
    edited April 2016
    Please add
    cstukenberg@fhn.org

  • mahmed1mahmed1
    edited April 2016
    me too!

    mahmed1@bronxleb.org

    Thanks,

    Mohmmad

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, May 22, 2012 1:31 PM
    To: Ahmed, Mohammed
    Subject: Re: [cdi_talk] Policy and Procedures

    I would like a copy- dsmith12h@aol.com

    Debbie Smith, RN; CCDS
    Certified Clinical Documentation Specialist
    UT Southwestern Medical Center at Dallas
    5909 Harry Hines Blvd.
    Dallas, TX 75390
    214-645-5217




  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited April 2016
    I've just sent out the attachments to 23 folks (all requests I had received up to now).
    I'll send another batch out sometime tomorrow.

    Don

  • epraczepracz
    edited April 2016
    Hi Don,
    Can you please add me on tomorrow list to send out.
    pracze@ohsu.edu

    Thank You,
    Eileen

  • clare.garrardclare.garrard
    edited April 2016
    I would also

    Thanks!

    Clare

    Clare.garrard@baycare.org

  • vdavis2vdavis2
    edited April 2016
    TY DON!!! :)

    Vicki S. Davis, RN CDS
    Clinical Documentation Improvement Manager
    Health Information Management Department
    Alamance Regional Medical Center
    Office (336) 586-3765
    Ascom Mobile (336) 586-4191
    Fax (336) 538-7428
    vdavis2@armc.com

    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens

  • jpricejprice
    edited April 2016
    Please include me in your "batch"..thanks so much!
    joprice@azkrmc.com

  • pagebrpagebr
    edited April 2016
    I would like the info also
    Thanks

    Brigitte Page, RRT, RN
    UM/Clinical Documentation Improvement
    Upstate University Hospital
    750 E. Adams Street
    Syracuse, NY 13210
    315-464-5854


  • Linda_RhodesLinda_Rhodes
    edited April 2016
    Hi Don,
    Please include me in your next batch, also.
    linda.rhodes@nhrmc.org

    Thanks,
    Linda


    Linda Rhodes RN, BSN, CCDS
    Manager Clinical Documentation Improvement
    New Hanover Regional Medical Center
    Wilmington, North Carolina
    Office # 910-815-5544
    Cell " 910-777-8344
    e-mail : linda.rhodes@nhrmc.org
    >>> CDI Talk 5/23/2012 10:02 AM >>>
    Please include me in your "batch"..thanks so much!
    joprice@azkrmc.com

  • Unknown
    edited April 2016
    Me too
    Thanks
    tsimpson@wrmc.com

  • Unknown
    edited April 2016
    And Me!!
    Tracey Carey RN
    Clinical Documentation Specialist
    UAMS
    501-686-7421
    TTcarey@uams.edu


  • ddraizeddraize
    edited April 2016
    If you don't have put in forms and tools could I also get a copy?
    Thanks

    Diane Draize RN, CPUR,CCDS
    Clinical Documentation Specialist

    Ministry Door County Medical Center
    diane.draize@ministryhealth.org
    920-743-5566 ex 3143

    We earn trust by working together as One Ministry to keep PATIENTS FIRST in everything we do






  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited April 2016
    I've sent out batch #2 as well as replying to direct emails.

    I'd like to encourage feedback & suggestions on these as people do review them. I know there are a couple of things I'd like to tweak & adjust. I also suspect there is at least one thing that I've missed and might really regret not having the suggestion made.

    Thanks,
    Don

  • Unknown
    edited April 2016
    Hi Don, Did you get my direct email? I heard about the 'bounce backs' but mine did not.

    -Jane


  • kmaceykmacey
    I would love a copy of the P&P if possible, thanks Don
  • kmaceykmacey
    Vanessa >would you be willing to share with me as well? We are still in our infancy and are trying to beef up our program, so any assist would be appreciated, Thanks
  • vanessa.falkoffvanessa.falkoff
    edited April 2016
    Don,
    Was this to me? If so, please send me your email address.
    :)

    Vanessa Falkoff RN
    CDI Coordinator
    UMC
    vanessa.falkoff@umcsn.com
    702-383-7332



  • kmaceykmacey
    I sent the request but did not realize you needed to add additional info, I guess I am spoiled :),
    email address kmacey@cvph.org
  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited April 2016
    I know there were a number of requests for the scrubbed P&P that I offered to share. I made every effort to send out to everyone that asked, if I missed anyone (or if the email didn't go through), my apologies.

    However, all 6 of those documents are now posted in the Forms & Tools library for anyone interested.

    Don

  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited April 2016
    Have you taken a look in the Forms & Tools library? There are several examples in there, both some that I'd contributed a few years ago as well as some others. Certainly would review carefully given that a few years have passed ...


    Donald A. Butler, RN, BSN
    Manager, Clinical Documentation Advisor Program
    Vidant Health, Greenville NC
    252-847-6855
  • Unknown
    edited April 2016
    We add policies if our team feels like there needs to be something in writing, but this is an example of what we have so far:
    CDI Compliance
    CDI Mission
    CDI Productivity
    Closing or retiring a chart
    Auditing and reconciliation
    Process for coding questions
    What to do in case of unanswered queries
    Data reporting
    Internal escalation policy
    Telecommuting (we've started a pilot project with 2 staff)
    Operational definitions of query impact
    Several internal operations policies

    Linda

    Linda Haynes, RHIT, CCDS | Manager, Clinical Documentation Improvement | Legacy Health
    19300 SW 65th Ave. | Tualatin, Oregon 97062 | 503-692-8862 | lhaynes@lhs.org

Sign In or Register to comment.