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: HIV Disease/AIDS
Definition: HIV Disease is caused by human immunodeficiency virus, of all types, with destruction of CD4+ T-lymphocytes that help mediate the body’s immune response to infection. · The virus is bloodborne · It is most often transmitted through: o ...
CDI Tips: Myocardial Injury
Myocardial Injury and Acute Myocardial Infarctions Acute Myocardial Injury: Elevated cTN value above the 99th Percentile upper reference limit (URL). The injury is considered acute if there is a rise and /or fall of cTN values. Acute Non-Ischemic Myocardial Injury:...
CDI Tips: Pneumonia
Pneumonia Pneumonia: An inflammation of the air sacs in one or both lungs caused by infection due to several organisms including bacteria, viruses, and fungi. It can also be caused by inhaling gases, toxic fumes, and pollutants or by aspiration. Obstructions of the...
CDI Tips: Sepsis
SepsisSepsis: A clinical systemic, dysregulated host response to infection. It causes extensive inflammation throughout your body that can lead to organ failure and shock if not treated with early intervention. The term sepsis covers a broad group of conditions:...
CDI Tips: Encephalopathy
EncephalopathyEncephalopathy: "Any diffuse disease of the brain that alters brain function or structure" according to the National Institute of Neurological Disorders of Stroke. The term encephalopathy covers two broad groups of conditions: Acute encephalopathy - is...
CDI Tips: Malnutrition
Malnutrition Malnutrition: Deficiencies, excesses, imbalances, in a person's intake of energy and/or nutrients. The term malnutrition covers 2 broad groups of conditions: 1) ‘Undernutrition’—which includes stunting (low height for age), wasting (low weight for...
CDI Tips: Pancytopenia
PancytopeniaPancytopenia: A hematologic condition where there is a lower-than-normal number of red and white blood cells and platelets in the blood. Common etiologies include, but are not limited to: Autoimmune disorders Bone marrow disorders Genetic disorders...
CDI Tips: Cerebral Edema & Brain Compression
Cerebral Edema & Brain CompressionCerebral Edema Definition: Swelling of the brain. Can result from a variety of derangements that can stem from trauma, hypoxia, infection, CVA, intracerebral hemorrhage, metabolic derangements, hepatitis, Reye syndrome, carbon...
CDI Tips: Atrial Fibrillation (AF)
Atrial Fibrillation (AF) Paroxysmal AF Definition: Episodes terminate either spontaneously or with treatment within 7 days; may recur Persistent AF Definition: AF is continuous and lasts > 7 days, fails to terminate spontaneously Long-standing Persistent AF...
CDI Tips: Debridement
Debridement Excisional Debridement Definition: The surgical removal or cutting away of devitalized tissue, necrosis, and slough. Non-Excisional Debridement Definition: The nonoperative brushing, irrigating, scrubbing, or washing of devitalized tissue, necrosis,...
