• Queries should be answered in your daily progress notes

Remember: do not write “in response to CDI query”

Instead you can note “documentation clarification”

  • Avoid use of the copy and paste function to maintain updated progress notes
  • Remember to include present on admission (POA) status of each condition
  • When documenting “rule out condition” it is important to note if the condition has been “ruled in” or “ruled out” before discharge
  • A cause and effect relationship cannot be assumed and must be documented by the provider

*Examples: > UTI due to foley catheter

> GI bleed due to coagulopathy related to Coumadin therapy

  • Each diagnosis you are monitoring and treating should be included in your progress notes and discharge summary
  • Signs and symptoms should be linked to a diagnosis when known
  • Avoid the use of abbreviations and acronyms
  • Include acuity of each diagnosis
  • Document significance of abnormal test results

Remember your CDI team is available to assist you.  Please reach out with any questions you may have!