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: Encephalopathy

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

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

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

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)

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

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,...

CDI Tips: Coma

CDI Tips: Coma

ComaDefinition: Deep state of unconsciousness where patients are unable to move or be aware of or respond to their surroundings with loss of thinking abilities however retain non-cognitive function and normal sleep patterns.Diagnostic CriteriaA comprehensive...

CDI Tips: Pathological Fractures

CDI Tips: Pathological Fractures

Pathological FracturesDefinition: A bone fracture that occurs without adequate trauma, caused by an underlying disease.Diagnostic CriteriaIdentified in Radiology/Diagnostic Imaging such as X-Ray, CT, MRI, or bone scans. There are various underlying causes for...

CDI Tips: Hypertensive Crisis

CDI Tips: Hypertensive Crisis

Hypertensive CrisisDefinition: HTN: Systolic blood pressure (SBP) of 130mm Hg or more and/or diastolic blood pressure (DBP) of more than 80mm Hg HTN Crisis: Generic term to describe hypertensive urgency or hypertensive emergency, typically seen with elevated blood...

CDI Tips: Respiratory Failure

CDI Tips: Respiratory Failure

Respiratory FailureDefinition: Syndrome where the respiratory systems fail in either or both the gas exchange function or oxygenation and carbon dioxide elimination. Recognized as either hypoxemic or hypercapnic.Coding Considerations:Review the circumstances of...