Chart Review Worksheet?

Snuggs105Snuggs105
in ACDIS CDI Apprenticeship
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!

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