Question

tcrosslintcrosslin
in CDI Talk Archive
I am pretty sure I read somewhere that a diagnosis had to be documented in 2 places in the record in order for the coder to code it. Maybe I dreamt it. Can anyone tell me if this is true and if so where to find this info?

Theresa Crosslin RN CM
Cookeville Regional Medical Center
931-783-2078
TCrosslin@crmchealth.org

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Comments

  • candersoncanderson
    edited April 2016
    Please share how you define Functional Quadriplegia. If patient can move limbs however, cannot use limbs purposefully and she is fully dependent for all ADL's., Can you Query for Functional Quad? Patient reviewed had prior CVA and Dementia, unable to ambulate, and she is aphasic. Care givers use a Hoyer lift to transfer from bed to chair . She is able to move limbs and withdraws limbs to painful stimulation. Thank You


    Cyndy
    Cyndy Anderson, RN
    Clinical Documentation Specialist
    Health Information Management
    Signature Healthcare
    Exceptional quality, service, and compassion: That's our Signature
    680 Centre Street
    Brockton, MA 02302
    Desk 508-941-7858
    Cell 508-491-6375




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