More CDI Resources Online
The online version of the May practice brief “Guidance for Clinical Documentation Improvement Programs” includes two additional, Web-only appendixes.
Appendix B outlines possible policies and procedures that may be used for new or existing CDI programs. The CDI department must be governed by written policies and procedures. These policies and procedures should be developed with the assistance of other departments affected by clinical documentation, including, compliance, case management, and HIM.
Appendix C provides more examples of leading and nonleading queries. Queries may take many forms, but they are never intended to leave the provider to one desired outcome.
For more CDI guidance, check out AHIMA’s “Clinical Documentation Improvement Toolkit.”