CDIP From AHIMA's Clinical Documentation Improvement, Achievin... file:///C:/Users/HP/Desktop/New%20fl/CDIP%20From%20AHIMA
CDIP From ANIMA’S Clinical Documentation
Improvement Achieving Excellence
by Ruthann Russo
1. CDI program data includes
Answer 1. All cases that were reviewed
2. Number of cases with queries
3. Nature of the query
4. Physician response to the query
2. Queries should only be asked
Answer 1. If there is clinical evidence that the docu- mentation is imcomplete or does not meet
one of the seven criteria for high-quality clinical documentation.
2. By an individual with solid clinical knowledge.
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3. In an open-ended manner (no yes or no questions)
4. In a nonleading manner.
5. To the individual whose documentaion is in question or who is responible for
interpreting test results or other data in the patient's record.
3. Query process and procedure should address
Answer 1.When queries will be asked.
2. Who will ask queries and to whom queries will be asked.
3. The hospital's responsibility in supporting the quering process.
4. The physician's responsibility in responding to queries.
5. Acceptable ways to responding to queries.
4. Examples of when a query is required may include
Answer 1. Documentation of reportable conditions or procedures is conflicting, ambigious, or is
otherwise incom- plete.
2. Abnormal diagnostic test results indicate the possible addition of a secondary diagnosis or
higher specificity of an already documented condition.
3. The patient is receiving treatment for a condition that has not been documented.
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4. Abnormal operative or procedureal findings are not documented.
5. It is unclear as to whether a condition was ruled out.
6. The pricipal diagnosis is not clearly identified.
5. Septicemia
Answer A systemic disease with the presence and persistence of pathogenic micro-organisms or
toxins in the blood. No longer considered synonymous with sepsis.
6. Sepsis
Answer Sepsis is SIRS due to an infection . Infection can originate anywhere in the body and be
triggered by a bacterial, viral, parasitic, or fungal infection.
7. Severe Sepsis
Answer SIRS due to infection with organ dysfunction. Sepsis associated
with acute dysfunction in one or more organs.
Organ dysfunction bay be cardiovascular, renal, respiratory, hepatic, hematological, central
nervous system, or metabolic acidosis.
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