Clinical Documentation Improvement (CDI)

Clinical Documentation Improvement (CDI)

Expected Mortality CHF, COPD & Afib WOB, Sats, RR BiPAP

ABG results Thin, sunken temples BP, gtts started Expected Mortality Rate: 1.7% CHF, COPD & Afib ADD:

Respiratory Failure Acidosis Decubitus ulcer Malnutrition

Cardiogenic Shock Expected Mortality Rate: 36.3% Expected Mortality PNA Acute COPD

PNA PNA Acute COPD Acute COPD Add: MODIFY: Malnutrition Malnutrition, SEVERE Decubitis Ulcer Decubitis Ulcer, STAGE IV

Mortality Rate: 0.3% Mortality Rate: 2.3% Mortality Rate:

9.2% HCAP translates / codes to Simple pneumonia Consider: PNA, possibly due to: gram negative organism Specific suspected organism

The Extra Step: Include ALL chronic conditions present and stable but managed Cancer Primary vs Secondary Specify ALL metastatic sites Active Remission Resolved Include all associated diagnoses

Urosepsis translates / codes to Simple UTI Consider: Sepsis from a UTI The Extra Step: For each medication Associated diagnosis

For each ordered study Suspected diagnosis When is a PE resolved?? If PE is felt still present & being treated: Identify as acute or subacute Even if from a recent admission ACUTE CHF translates / codes to CHF, not further specified

Consider: Specify diastolic &/or systolic Will then capture ACUTE The Extra Step: For each abnormal finding (Lab, radiology, exam) Describe clinical significance INCLUDE suspected cause

NAME IT ESRD With fluid overload or pulmonary edema Is it NON-CARDIOGENIC? Or is it CHF What is the cause (non-compliance?) END STAGE COPD with

continuous home O2 translates / codes to COPD only Consider: COPD, Acute Exacerbation Acute & Chronic Respiratory Failure The Extra Step: Specify supportive facts for diagnosis

Quantify Risk Stratification History of?? Is the condition truly resolved? Or is it chronic & stable with ongoing management Post-operative Frequently translates / codes to

complication Caution on intended meaning: Temporal vs Causative relationship Clarify if INTEGRAL to procedure or EXPECTED part of recovery period The Extra Step: Include ALL diagnosis being considered, worked up or treated possible, probable, likely

Update diagnosis status Ruled in or out Remains possible Altered Mental Status: Is it? Acute Confusion Chronic dementiaor acutely worse? Acute delirium Encephalopathy

Include specific suspected causes Symptoms (dyspnea, chest pain, dizziness, weakness, fever) translates / codes to ???? Explicitly state suspected cause

d/t arrythmia, COPD, CHF, PNA, etc. d/t unstable angina or CAD, pleurisy, GERD, chest wall pain d/t hypotension / dehydration likely source, or bacterial infection unknown source The Extra Step:

Relate conditions & State connections UTI due to Foley specific conditions due to prior CVA Manifestations & Sequela Manifestations of disease WITHOUT Explicit linkage translates / codes to

Uncomplicated DM, HTN Consider use adjective or due to Diabetic nephropathy or Hypertensive CHF The Extra Step: Carry diagnoses throughout stay Include ALL diagnoses at discharge Acute Chronic Resolved during stay

Condition with VS (differential diagnoses) translates / codes to Condition ONLY Consider: 1. Identify primary suspected cause

(then follow with alternatives) 2. Clearly indicate RULED IN & OUT diagnoses Use STRONG terms: Failure Shock Coma Encephalopathy The Extra Step:

Renal Status CKD Stage? Acute Renal Failure due to Use STRONG Qualification & Links: Acute, Acute on Chronic Sub-acute, Chronic Congenital Exacerbated Uncontrolled

Mild, Moderate, Severe Due to, Secondary to Unstable The Extra Step: Abbreviations Always spell it out the first & last time Different areas expertise & knowledge Prevent confusion & errors

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