CDI 1010 Record Review & Document Clarification
Upon review of medical record cases, students discuss opportunities for documentation improvement of diagnoses and procedures regarding their level of specificity and presence on admission. This course reviews how to compose queries regarding potential fraud and/or compliance issues, conflicting diagnoses, abnormal findings. It also studies requirements for documentation of query response and tracking of queries. Students learn to develop policies for documentation of query responses in the record, and they learn to establish official policy and procedures related to CDI query activities. Students learn to develop policies regarding various stages of the query process and timeframes to avoid compliance risk.