1. List and describe the seven criteria for high-quality clinical documentation. Why is a CDI program necessary? Don’t physicians document correctly already?
2. List and describe key types and sources of documentation. Why can’t nursing notes be used?
3. Describe the steps to development and implementation of a CDI program. Is it better to hire a consultant to set up the program or start one independently?
4. Describe the CDI process. What should happen if the HIM coder’s abstract does not agree with the CDI specialist worksheet?
5. Finally, develop an appropriate physician query to resolve data and coding discrepancies (make your own scenario.)
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