This query form is a request for documentation clarification of HIV Status. It was submitted by Paul Evans, RHIA, CCS, CCS-P, supervisor of clinical documentation integrity at Sutter Health in San Francisco. It was originally posted on the Association of Clinical Documentation Improvement Specialists website.
Christine Lewis, MHA, RHIA, CCS, CCS-P, health information services coding and record processing manager at the Medical University of South Carolina in Charleston, shared this job description, originally printed in Medical Records Briefing, in use at her hospital with those who might be wondering how to structure the position at their own facility.
Deborah K. Hale, CCS, CCDS, president of Administrative Consultant Service, LLC, in Shawnee, Okla, provided this pocket card to use when determining whether a patient should be placed in observation.
This form provides a sample query for gastritis, which can be coded to a higher specificity in ICD-10-CM. Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI education director at HCPro, Inc., in Danvers, Mass., provided the form.
Use this query when the physician admits a patient with a history of alcoholism but provides no diagnosis. Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI Education Director for HCPro Inc., in Danvers, Massachusetts, provided this query.
Auditing and monitoring, Health information management
The Office for Civil Rights recently published its audit protocol for its current privacy and security audits. These protocols give healthcare organizations an inside look at the inspection process. Our sister publication, Briefings on HIPAA, recently published this breakdown of the audit protocols key activities.
Audrey G. Howard, RHIA, and Cheryl Manchenton, RN, BSN, of 3M Health Information Systems provided this example of a query for a documentation of a case involving a urinary tract infection due to insertion of a Foley catheter.
This prequalification checklist for hyperbaric oxygen (HBO) therapy candidates was created by Gloria Miller, CPC, CPMA, and provides information on what diagnoses qualify for coverage, and what additional information about the candidates is required.
