Forms

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.

Hospitals and physicians are transitioning from ­paper and hybrid medical records to EHRs. Because physicians are also requesting electronic versions of other information, such as newsletters, consider keeping them informed about documentation and coding through the use of e-blasts: mass emails sent to physicians. An e-blast should have a subject line that ­captures physicians' attention. Beginning with a greeting such as "Dear Dr. _____" is a matter of personal preference. Use these examples of brief e-blast messages pertaining to CDI from HCPro’s CDI Toolkit to create your own messages.

Paula Lewis-Patterson, BSN, MSN, NEA-BC, the clinical administrative director of the ambulatory treatment center at The University of Texas MD Anderson Cancer Center in Houston, provided these and other examples of good and poor documentation for infusions as part of HCPro's audio conference, 2012 Injections and Infusions: CPT Changes, Nursing Documentation Requirements, and Billing Process Review.
 

This form highlights the required documentation necessary for common interventional radiology procedures, including catheterizations, imaging guidance, and therapeutic interventions. Stacie L. Buck, RHIA, CCS-P, RCC, CIC, of RadRX.com created this form.

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.

These documentation examples from Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, show the type of information providers will need to note in order for coders to accurately apply BMI codes in both ICD-9-CM and ICD-10-CM.

This form represents one example of a possible request for diagnostic clarification/confirmation of diagnosis donated by Paul Evans, RHIA, CCS, CCS-P, CCDS.

ICD-10-CM and ICD-10-PCS should eventually result in better data capture nationwide. The change means healthcare organizations urgently need to educate providers on the importance of improved patient care documentation. The Winthrop University Hospital clinical documentation improvement (CDI) specialists and HIM team have presently implemented a new query for acute myocardial infarctions to help. The newly created forms incorporate the language necessary to capture documentation within these two new areas of enhanced specificity. The team reviewed the queries' content, structure, design, and use to ensure they would be effective and accepted.