Clinical Indicator Query

tkreilingtkreiling
in CDI Talk Archive
Does anyone have a query or suggested wording that they use when they see a diagnosis without a whole lot of evidence clinically of the condition? For example AKI charted with only a one time minimal elevation of BUN/Cr?
Thanks in advance,
Tara RN, CCDS

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    This is our general template. If you have facility-approved definitions or anything like that, you could add specificity.

    Hope that helps :)

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • tkreilingtkreiling
    edited May 2016
    Yes! Thanks so much!

    Tara RN,CCDS
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