Clinical Documentation Integrity Tips
Monthly CDI tips & friendly reminders from the e4health clinical documentation team — built for the realities of your day-to-day workflow.
CDI Tips: Social Determinants of Health
Topic: Social Determinants of Health Definition: Social determinants of health (SDOH) are the nonmedical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, worship, and age. Diagnostic Criteria: Codes describing...
CDI Tips: Intellectual Disability
Topic: Intellectual Disability Definition: Intellectual disability, formerly known as mental retardation, characterized by: Impairment of intellectual function (IQ< 70) Associated with adaptive behavior problems Begins prior to age 18 Disrupts abilities necessary...
CDI Tips: Adult Obesity
Adult Obesity Definition Obesity: Recognized as a BMI > 30. Morbid obesity: BMI > 40 or > 35 with at least one obesity related comorbid condition such as diabetes, heart disease, stroke, hypertension or arthritis. Drug-induced obesity (iatrogenic obesity):...
CDI Tips: Antimicrobial Resistance
Antimicrobial Resistance Definition The resistance of micro-organisms like bacteria, viruses, fungi, and parasites to one or more classes of antimicrobial drugs. Antimicrobial Resistance (AMR) can lead to the following: Infections that last longer, lengthen hospital...
CDI Tips: Electrolyte Disorders
Electrolyte Disorders Electrolyte imbalances are defined as electrolyte levels that fall outside the normal reference ranges established by institutional laboratories. Management of these imbalances typically includes correction of the abnormal values, daily...
CDI Tips: Anemia
Anemia Definition: Anemia is a condition in which the number of red blood cells or the hemoglobin (Hgb) concentration within them is lower than normal. Common types of anemia: Iron deficiency, Aplastic, Hemolytic, and Acute blood loss and Chronic blood loss Hgb is...
CDI Tips: Cystic Fibrosis (CF)
Cystic Fibrosis (CF)Definition: A hereditary disorder characterized by thick secretions in the lungs, pancreas, liver, intestine, and other organs resulting in multi-system disease. Median survival is approximately 50 years. Diagnostic Criteria Lab work: Elevated...
CDI Tips: Immunodeficiency
Immunodeficiency or an immunocompromised state refers to a weakened immune system that results in more frequent infections that are more severe and last longer than usual. There are two types of immunodeficiency disorders: Primary and Secondary. Primary disorders...
CDI Tips: Functional Quadriplegia
Explore the causes, symptoms, and treatment options for Acute Tubular Necrosis, a severe disability caused by a condition that does not involve the spinal cord.Describes a complete inability to move due to severe disability caused by a condition that does not involve...
CDI Tips: Acute Tubular Necrosis (ATN)
Explore the causes, symptoms, and treatment options for Acute Tubular Necrosis, a critical condition affecting kidney function.Acute Tubular Necrosis (ATN) involves the death of tubular epithelial cells that form the renal tubules. The etiology is intrarenal,...