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: Poisonings vs. Adverse Reactions vs. Toxic Effects vs. Underdosing
Poisonings vs. Adverse Reactions vs. Toxic Effects vs. Underdosing DefinitionPoisoning: reaction to the improper use of a medication. This can include either:Wrong substanceWrong doseWrong personWrong Route of administrationTaken in combination of alcohol, illicit...
CDI Tips & Friendly Reminders: Acute Kidney Injury (AKI)
Acute Kidney Injury (AKI) DefinitionAn abrupt (within hours) decrease in kidney function, which encompasses both injury (structural damage) and impairment (loss of function). Etiology categorized as:Pre-Renal: Caused by any type of reduced blood flow to the...
CDI Tips: Properly Capturing Lactic Acidosis
A recent discussion regarding lactic acidosis in a patient with sepsis has prompted a review of some important points that need clarification. First and foremost, lactic acidosis is not considered inherent to Sepsis. Additionally, acidosis is not noted as an...
CDI Tips: Pregnancy and Mpox
The World Health Organization (WHO) declared monkeypox a public health emergency of international concern on July 23rd, 2022. Following consultations with global experts, WHO began using a new preferred term, “mpox” as a synonym for monkeypox. Both names are...
CDI Tips: Dementia
Dementia: Will we need more queries? The short answer is yes! We need documentation of none, other, or a specified type of mood disorder. But here is the long answer: “Dementia The ICD-10-CM classifies dementia (categories F01, F02, and F03) on the basis of the...