clarifications as part of medical record

tiffany_susantiffany_susan
edited May 2016 in CDI Talk Archive
Good afternoon everyone! I know I recently posted the question regarding
clarifications as permeant parts of the medical record. I am looking for
anyone who does this and would be willing to share how this has worked for
them. Have any of these clarifications been part of the audit process? Do
you use the same guidelines as a retro query or have you adjusted the
guidelines to encompass the concurrent aspect?

Thank you,
Susan Tiffany RN, CDS
Supervisor
Clinical Documentation Program
Robert Packer Hospital & Corning Hospital
570-882-6094 pager 465
Fax 570-882-6768
Tiffany_Susan@guthrie.org



Comments

  • Unknown
    We use some preprinted progress notes that are in the ACDIS library, i believe there are several others in there as well. These are for the diagnoses that we query for frequently, such as CHF, type of anemia, type of debridement, etc.
    Julie Doy,
    Mercy Medical Center, Des Moines
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