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Cardiology-CHF
Pulmonology-Pneumonia
O LD
CHF exacerbation
NEW
Acute s ystolic and/or
diastolic Heart Failure
O LD
Community Acquired
Pneumonia
Decompensated CHF
Acute on chronic systolic
and/or diastolic Heart
Failure
Acute on chronic systolic
and/or diastolic Heart
Failure
Chronic systolic and/or
diastolic Heart Failure
Healthcare Acquired
Pneumonia
Mild CHF
Compensated CHF
Pneumonia
COPD, asthmatic
bronchitis
Endocrinology-Diabetes
O LD
IDDM, NIDDM
NEW
Type I or Type II DM
Poor control, labile,
stable, elevated glucose
Type I or Type II DM
controlled or
uncontrolled
*Please dictate as much as possible*
NEW
Suspected, probable,
possible (organism type)
pneumonia
Suspected, probable,
possible (organism type)
pneumonia
Suspected, probable,
possible (organism type)
pneumonia
COPD exacerbation, COPD
exacerbation w/asthma,
COPD exacerbation w/acute
bronchitis
Hematology-Anemia
O LD
Anemia
Anemia due to GI
bleed
NEW
Must specify anemia type:
(acute blood loss anemia,
iron deficienc y anemia,
pernicious anemia, anemia of
chronic kidney disease, etc.)
Acute blood loss anemia
CDI Team: Maria Mann RN,BSN,MSHL,CCDS
Cherlene Woods RN, BSN
Simone Picou RN, BSN, MS, CCM
Jacqueline Boreland RN-BC, MSN, OCN
HIM Clinical Documentation Improvement Program
Updated 6/11 MM
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Nephrology-Acute Renal Failure & CKD
O LD
Chronic Renal
Insufficiency, Renal
Insufficiency
Acute Kidney Disease,
Pre-renal Azotemia,
Acute on Chronic CKD,
Chronic Renal Failure
OLD
Open wound/ulcer
Acute Renal Failure
(specify cause), Acute
Renal Failure on CKD
(stage), End Stage
Renal Disease
Decubitus ulcer,
pressure ulcer
Helpful Hints
O LD
Transbronchial
biopsy
DC Summary
documentation
Hypertensive
Emergency
Malnutrition
Altered Mental
Status
Wounds
NEW
Chronic Kidney Disease
(must be staged)
NEW
Specify wound site and type
of wound (i.e., pressure
ulcer)
Please document if present
on admission.
Helpful Hints
NEW
Lung or Bronchial biopsy
O LD
Urosepsis
NEW
Sepsis due to UTI
All diagnoses, including
those suspected, possible
or resolved, must be
documented
Accelerated or Malignant
Hypertension
Specify severity: Mild,
Moderate, or Severe
Infiltrate on CXR
Pneumonia (specify type) culture results are not
required for suspected
pneumonia type
W rite out diagnosis
Document alteration;
probable underlying
encephalopathy type
*Please dictate as much as possible*
Use of ↓↑ signs
Insufficiency,
compensated,
decompensated
H&P documentation
Specify if condition is acute,
chronic, or acute on chronic
Please list all co-morbid
conditions
Questions? Please see the
CDI website on Gwinnett Work for more information.
HIM Clinical Documentation Improvement Program
Updated 6/11 MM
MS-DRG TOOL
HIM Clinical Documentation Improvement Program
MS-DRG TOOL
Updated 6/11 MM