CDIP Domain 3 Presentation

Legibility - Answer- Clear enough for the reader to comprehend and easily decipher. Copy/Paste forward unclear when dx start or end Reliable - Answer- Trustworthy, safe and yielding the same result when repeated. Orders transfusions for a GI Ulcer? Not Reliable Precise - Answer- Accurate, Exact and Strictly Defined. Type of PNA. Complete - Answer- Maximum Content and is Thorough. Fully addressed all concerns Consistent - Answer- Not Contradictory/conflicting dx btw providers Clear - Answer- Thoroughly describes what's happening w/ the patient. State symptoms if there's no definitive dx Timely - Answer- Record is prepared by provider at the time point it is needed by clinicians for patients care updated regularly for continuity of care When to Query? - Answer- Clinical evidence for a higher specificity? Clinical indicator of a dx not present? Cause/Effect relationship btw 2 conditions? presence of underlying cause when admitted w/ symptoms? Doc'd only treatment w/o dx? POA indicator stats? Illegibility of docs? procedure specificity? ICD PCS Components - Answer- Section (Medical/Surgical) Body System Root operation (excision) Body Part Approach Device Qualifier Ethical - Answer- conforming to accepted standards of conduct. Avoid fraud or compliance issues types of ethical queries - Answer- Give facts and ask to interpret Yes/No exceptions (POA stats, dx already present, cause and effect relationships, resolving conflicting docs) Open ended multiple choice (they make final judgement) Provide reasonable options based on clinical indicators Don't query -