Physician Pocket Cards
Many of us have made, or used, pocket cards that focus on diagnosis, etc.
BUT, I was wondering if anyone has a pocket card that focuses on 'tips' that would help the physician, especially for their more direct interests (such as surgical complications, E&M coding, etc.).
Please discuss any such card you have (or share!!).
Lets also put our heads together and think about what might be good to put on such a card.
For example:
1--NEVER document 'post-op' -- it is too confusing whether that is intended as a simple temporal relationship or as establishing a complication of the surgery.
2--Make sure to include the relevant diagnosis for ALL medications given during the stay (especially continued home meds) & be as specific as possible. This supports the number of problems being managed, supports the complexity of decision making, etc.
Don
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BUT, I was wondering if anyone has a pocket card that focuses on 'tips' that would help the physician, especially for their more direct interests (such as surgical complications, E&M coding, etc.).
Please discuss any such card you have (or share!!).
Lets also put our heads together and think about what might be good to put on such a card.
For example:
1--NEVER document 'post-op' -- it is too confusing whether that is intended as a simple temporal relationship or as establishing a complication of the surgery.
2--Make sure to include the relevant diagnosis for ALL medications given during the stay (especially continued home meds) & be as specific as possible. This supports the number of problems being managed, supports the complexity of decision making, etc.
Don
------------------------------------------------------------------------------
The contents of this e-mail (and any attachments) are confidential, may be privileged and may contain copyright material. You may only reproduce or distribute material if you are expressly authorized by us to do so. If you are not the intended recipient, any use, disclosure or copying of this email (and any attachments) is unauthorized. If you have received this e-mail in error, please notify the sender and immediately delete this e-mail and any copies of it from your system.
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Comments
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Robert.Hodges2@va.gov
Roberta Bosanko-Cera MS, CCS-P, CPMA, CPC-P, CEMC
AHIMA ICD-10-CM/PCS Ambassador & Training Instructor
Director, Finance ICD-10
Hospital For Special Surgery
535 E 70th Street
New York, NY 10021
bosankor@hss.edu
212-774-2906 Office
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The attached document is one file with 26 tabs, one for each card. The document can be opened and edited in Microsoft Publisher. It's designed to print 4 cards per sheet.
Hope it helps
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
Vanessa Falkoff, RN
Clinical Documentation Coordinator
University Medical Center of Southern Nevada
office (702) 383-7322
cell (702) 204-0054
vanessa.falkoff@umcsn.com
____________________________________________________________
Julie Draper, R.N.
Compliance Documentation Management Nurse
Mercy Medical Center - North Iowa
draperj@mercyhealth.com
Phone 641-428-7032 (voice mail)
Pager 641-428-7000 beeper #720
Fax 641-428-7080
Have a great CDI Day!
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
I do love how people share their expertise and experience here. It's nice to give back
Robert
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
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"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens