GOLDEN RULES OF CLINICAL DOCUMENTATION INTEGRITY (CDI)

GOLDEN    RULES    OF    CLINICAL    DOCUMENTATION    INTEGRITY    (cdi)

DOCUMENT    DIAGNOSES    NOT    SIGNS/SYMPTOMS
SIGNS    AND    SYMPTOMS    DO    NOT    ADEQUATELY    RISK    ADJUST    QUALITY    METRICS

POSIBLE    PROBOBALY    SUSPECTED    LIKELY    DIAGNOSSES    ARE    ACCEPTABLE
MUSTBE    INCLUDED    IN    DC    SUMMARY    TO    BE    CODED

DOCUMENTATION    QUERIED    DIAGNOSES    IN    THE    MEDICAL    RECORD
DOCUMENT    ALL    DIAGNOSES    IN    THE    DC    SUMMARY
-ENSURES    DIAGNOSES    ARE    CODED
OJLY    CODED    DIANGOSES    ARE    USED    TO    RISK    A    DJUST    QUALITY    METRICS

DOCUMENT    PERSENT    ON    ADMISSION    WHEN    APPROPRIATE
QUALITY    METRICS    RISK    ADJUST    WITH    DIAGNOSES    CAPTURED    AS    POA
ONLY    DIAGNOSES    POA    ARE    ELIGIBLE    TO    BE    THE    PRINCIPAL    DIAGNOSIS
POA    STATUS    CAN    BE    ASSIGNED    AT    ANY    TIME

AVOID    HISTORY    OF,    INSTEAD    CONSIDER    "CHRONC"    OR    "AS    A    LATE    EFFECT".    "HISTORY    OF"    IS    CONSIDERED    A    REMOTE    CONDITION    WHICH    IS    NOT    ACTIVE    NOR    CHRONIC

ACOID    THE    TERM    "VERSUS"
CODERS    ARE    NOT    ALLOWED    TO    INTERPRET    DOCUMENTATION
WHEN    "VERSUS"    IS    DOCUMENTED    THE        DIAGNOSIS    IS    UNCLEAR

AVOID    THE    TERM    "TO    COVER"    INSTEAD    USE    THE    TERM    "TO    TREAT".    "TO    COVER"    IS   AN    AMBIGUOUS    TERM    THAT    REQUIRES    A    QUERY.    
GOLDEN RULES OF CLINICAL DOCUMENTATION INTEGRITY (cdi)

DOCUMENT DIAGNOSES NOT SIGNS/SYMPTOMS
SIGNS AND SYMPTOMS DO NOT ADEQUATELY RISK ADJUST QUALITY METRICS

POSIBLE PROBOBALY SUSPECTED LIKELY DIAGNOSSES ARE ACCEPTABLE
MUSTBE INCLUDED IN DC SUMMARY TO BE CODED

DOCUMENTATION QUERIED DIAGNOSES IN THE MEDICAL RECORD
DOCUMENT ALL DIAGNOSES IN THE DC SUMMARY
-ENSURES DIAGNOSES ARE CODED
OJLY CODED DIANGOSES ARE USED TO RISK A DJUST QUALITY METRICS

DOCUMENT PERSENT ON ADMISSION WHEN APPROPRIATE
QUALITY METRICS RISK ADJUST WITH DIAGNOSES CAPTURED AS POA
ONLY DIAGNOSES POA ARE ELIGIBLE TO BE THE PRINCIPAL DIAGNOSIS
POA STATUS CAN BE ASSIGNED AT ANY TIME

AVOID HISTORY OF, INSTEAD CONSIDER "CHRONC" OR "AS A LATE EFFECT". "HISTORY OF" IS CONSIDERED A REMOTE CONDITION WHICH IS NOT ACTIVE NOR CHRONIC

ACOID THE TERM "VERSUS"
CODERS ARE NOT ALLOWED TO INTERPRET DOCUMENTATION
WHEN "VERSUS" IS DOCUMENTED THE DIAGNOSIS IS UNCLEAR

AVOID THE TERM "TO COVER" INSTEAD USE THE TERM "TO TREAT". "TO COVER" IS AN AMBIGUOUS TERM THAT REQUIRES A QUERY.

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Sandbox Metrics: Structured Data Index 0, 163 boilerplate words
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