Chart Review Worksheet?

Hi All!

I am looking for a template I can print and use when reviewing the chart. I just started my first CDI job last week and I am already reviewing some charts and entering my findings in 3M (to be reviewed by my supervisor). I found that reviewing the chart in Meditech and writing down my findings is a good exercise for myself before jumping into 3M. This way I can go back and review and see what I missed when the coder or someone else reviews the file. I also find that I might write something down like.. PNA, but find a few progress notes later they are more specific and I can give a more specific code (vs.. entering it right away and forgetting to revise the specificity).

I was wondering if there is already a paper template out there (before everyone used the encoder software) that might be more specific and inclusive then what I made up. I've included on mine: PDX, SDX, PMH (including surgeries), Social (opioid/smoker/homeless etc.), Medications; labs & diagnostics, procedures. And then possible Query/questions I have.

Is there anything out there already in template form that can better assist me? Or anything I am missing to include in my review? Any help is appreciated!

Comments

  • You should be able to find a form from Lynn Sprayzak on the forms library. I have a copy and if you email me I will send to you if you can't find.

    Happy Thursday!

    Ann

    ann.donnelly@hillcrest.com

  • Hi, where can I find the "forms library".  I did not see a reference under the Resources tab.

    Thanks for your help!
  • it's the jan 7 2011 document


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