RE: [MARKETING] RE:good tip as we approach clinical indicator queries...
CI queries? Clinical Indicators?
Presuming that is what you mean, for malnutrition I look at the
dieticians assessment and if they document it I present it to the
provider and ask for the clinical significance and to document a
diagnosis and level of severity if it is. Normally I get a very good
response on these.
I do the same for other indicators as well even if documented by other
care givers. If it's in the health record I consider it fair game to
ask for the clinical significance of the finding, if any.
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
VHA CDI Council Member
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence
("I CARE")
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative,
Agile, Integrated
"We are dealing with Veterans, not procedures; With their problems, not
ours." --General Omar Bradley
Presuming that is what you mean, for malnutrition I look at the
dieticians assessment and if they document it I present it to the
provider and ask for the clinical significance and to document a
diagnosis and level of severity if it is. Normally I get a very good
response on these.
I do the same for other indicators as well even if documented by other
care givers. If it's in the health record I consider it fair game to
ask for the clinical significance of the finding, if any.
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
VHA CDI Council Member
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence
("I CARE")
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative,
Agile, Integrated
"We are dealing with Veterans, not procedures; With their problems, not
ours." --General Omar Bradley