Platinum members can access an ICD-10-PCS root operation word find. If you are not a Platinum member and you want to upgrade your account, please call customer service at 800-650-6787.
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Platinum members can access the webinar Deciphering Documentation and Coding Dilemmas for Altered Mental Status. If you are not a Platinum member and you want to upgrade your account, please call customer service at 800-650-6787.
This sample respiratory failure query was provided by Debra A. LeDeox, RN, CCDS, CDI coordinator at Mather Hospital in Port Jefferson, New York.
This sample has been reviewed and approved by the ACDIS Forms & Tools Library Committee. The committee recommends that, should you choose to use this sample, you adapt it to your particular programmatic needs, EHR system requirements, and organizational diagnostic criteria.
The committee also suggests that mature programs may want to simplify and consolidate some of the language in this sample in order to make it more concise. For example, the first two and the last two paragraphs of the query may be combined into one, greatly shortening the template. As providers are busy, they may not respond if the query is too lengthy. While the additional information in this sample may be a helpful educational tool for a newer program, mature programs should consider ways in which they could simplify the template to encourage provider response and limit query fatigue.
Use this sample physician query form for documenting sepsis as a template for your organization. Juli Bovard, RN, CCDS, CDI specialist at Rapid City (South Dakota) Regional Hospital shared this sample sepsis query form with the ACDIS CDI Talk networking group.