CDIP DOMAIN 3 RECORD REVIEW & DOCUMENT CLARIFICATION WITH VERIFIED SOLUTIONS

POA Present on admission Concurrent reviews CDI specialist reviews the patient record while the patient is in the hospital Brainpower Read More Ethical Conforming to accepted standards of conduct Ethical Queries Queries that do not lead the physician to a particular answer If you have two conflicting diagnoses by two providers, who should make the final decision? Attending physician Legible the record is clear enough for the reader to comprehend and easily decipher Reliable the content of the record is trustworthy, safe, and yielding the same result when repeated Precise the record is accurate, exact, and strictly defined Complete the record has the maximum content and is thorough Consistent the record is not contradictory Clear the documentation thoroughly describes what is happening with the patient Timely the record is prepared by the provider at the point it is needed by clinicians for patient care HAC Hospital Acquired Condition SOI Severity of Illness ROM Risk of Mortality Hospital Acquired Conditions conditions that will not be reimbursed if they occur in the hospital after admission PSIs Patient Safety Indicators Patient Safety Indicators set of indicators providing information on potential in-hospital complications and adverse events following surgeries, procedures, and childbirth