Clinical Documentation Improvement

Learning Activities



  • 2-Midnight Rule

    Objectives: Upon completion of this activity, the participants should be able to:

    • Identify the key elements needed, and documentation required, for appropriate inpatient admission under the 2-midnight rule
    • Review the exceptions to the 2-midnight rule that are compliant for an inpatient admission that spans less than 2 midnights

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    Presenter: Marianne Ries, M.D., M.B.A., CPE, Physician Advisor, Institute for Population Health and Care Transitions Management

     

  • Acute Gastrointestinal Bleeding

    Objectives: Upon completion of this activity, the participants should be able to:

    • Identify the major causes of Upper and Lower Gastrointestinal Bleeding
    • Describe appropriate procedures and radiographic evaluation for suspected Upper and Lower Gastrointestinal Bleeding
    • Identify patient risk factors for Upper and Lower Gastrointestinal Bleeding

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    Presenter: Marianne Ries, M.D., M.B.A., CPE, Physician Advisor, Institute for Population Health and Care Transitions Management

     

  • Acute Kidney Injury (AKI)

    Objectives: Upon completion of this activity, the participants should be able to:

    • Recognize the diagnostic possibilities associated with a wide range of renal pathologies
    • Discuss the documentation requirements to support accurate diagnosis of Acute Kidney Injury (AKI)
    • Recognize documentation requirements to distinguish various renal pathologies

     

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    Presenter: John Hall, M.D., M.S., JD, MBA, FRCPC, FCLM, CPE, Physician Advisor, Central Business Office and Strategic Revenue Services

  • Acute Respiratory Failure

    Objectives: Upon completion of this activity, the participants should be able to:

    • Define and classify acute respiratory failure
    • Describe appropriate diagnosis of hypercapnic respiratory failure
    • Describe appropriate diagnosis of hypoxic respiratory failure
    • Describe clinical signs and symptoms of acute respiratory failure
    • Describe how clinical signs and symptoms link with objective findings to diagnose acute respiratory failure

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    Presenter: Marianne Ries, M.D., M.B.A., CPE, Physician Advisor, Institute for Population Health and Care Transitions Management

     

  • Anemia

    Objectives: Upon completion of this activity, the participants should be able to:

    • Review the usual guidance for diagnosis
    • Recognize documentation required to support a valid diagnosis of anemia
    • Discuss documentation required for inpatient admission

     

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    Presenter: John Hall, M.D., M.S., JD, MBA, FRCPC, FCLM, CPE, Physician Advisor, Central Business Office and Strategic Revenue Services

  • Atrial Fibrillation

    Objectives: Upon completion of this activity, the participants should be able to:

    • Describe classification of paroxysmal, persistent chronic, and permanent Atrial Fibrillation
    • Identify the assessment elements and scoring of CHA2DS2-VASc Stroke Risk Assessmen
    • Identify and describe risk factors for the development of Atrial Fibrillation

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    Presenter: Marianne Ries, M.D., M.B.A., CPE, Physician Advisor, Institute for Population Health and Care Transitions Management

     

  • Chest Pain

    Objectives: Upon completion of this activity, the participants should be able to:

    • Identify and describe Type 2 MI
    • Describe the fourth universal definition of MI and the types of MI

    VIEW PRESENTATION

     

    Presenter: Marianne Ries, M.D., M.B.A., CPE, Physician Advisor, Institute for Population Health and Care Transitions Management

     

  • Clinical Documentation Improvement

    Objectives: Upon completion of this activity, the participants should be able to:

    • Explain how ICD-10 codes and DRG assignments are being used to determine severity of illness (SOI) and risk of mortality (ROM) scores, and how these are used for determining severity-adjusted clinical outcomes (O/E ratios), such as mortality, length of stay (LOS), and readmission rates (i.e., Value-Based Purchasing initiatives.
    • Describe that individual providers are now under the same level of scrutiny as hospitals have been, by virtue of MACRA/MIPS (Merit-Based Incentive Program) initiatives
    • Discuss how dependent hospital coders are on appropriate and specific provider documentation, both wording and clinical validation, for accurate determinations of ICD-10 codes, and how a CDI program is designed to help providers "get it right"
    • Review how hospital-acquired conditions (HACs) and patient safety indicators (PSIs) are determined by coders, how provider documentation can lead to inaccuracies in this determination, with subsequent quality and safety determinations.
    • Generalize the key factors in documentation for medical necessity determinations such as inpatient versus observation status for medical and surgical patients, as well as to help prevent denials, as medical records become more scrutinized.

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    Presenter: Andrew H. Dombro, M.D., Internist/Hospitalist, Healthcare Consultant, Speaker, and Writer

  • Encephalopathy

    Objectives: Upon completion of this activity, the participants should be able to:

    • Identify and describe differences between characteristics of Dementia and Delirium
    • Identify the primary diagnoses that are the most common source of acute encephalopathies

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    Presenter: Marianne Ries, M.D., M.B.A., CPE, Physician Advisor, Institute for Population Health and Care Transitions Management

     

  • Health Information Management

    Objectives: Upon completion of this activity, the participants should be able to:

    • Describe the differences between coding and CDI queries
    • Discuss the interaction between medical record specificity and coding specificity
    • Review the requirements for significant components of the medical record- MEAT components
    • Recognize the benefits to patients and practices of complete and specific documentation

    View Presentation

    Presenter: John Hall, M.D., M.S., JD, MBA, FRCPC, FCLM, CPE, Physician Advisor, Central Business Office and Strategic Revenue Services

  • Heart Failure

    Objectives: Upon completion of this activity, the participants should be able to:

    • Define heart failure and identify causal conditions
    • Identify physical exam findings characteristic of heart failure
    • Characterize different types of heart failure and how they are documented

    VIEW PRESENTATION

     

    Presenter: Marianne Ries, M.D., M.B.A., CPE, Physician Advisor, Institute for Population Health and Care Transitions Management

     

  • Malnutrition

    Objectives: Upon completion of this activity, the participants should be able to:

    • Recognize the importance of nutritional consultation in making a malnutrition diagnosis
    • Identify the six components of the ASPEN criteria for malnutrition
    • Explain the role of biomarkers in a diagnosis of malnutrition

    VIEW PRESENTATION

     

    Presenter: Marianne Ries, M.D., M.B.A., CPE, Physician Advisor, Institute for Population Health and Care Transitions Management

     

  • Observation

    Objectives: Upon completion of this activity, the participants should be able to:

    • Review the difference between patient status and services
    • Explain the limited ability to change the status of an inpatient
    • Discuss appropriate methods to stop observation services

    VIEW PRESENTATION

     

    Presenter: Marianne Ries, M.D., M.B.A., CPE, Physician Advisor, Institute for Population Health and Care Transitions Management

     

  • Pneumonia

    Objectives: Upon completion of this activity, the participants should be able to:

    • Identify the most positive predictive physical exam findings for community acquired pneumonia
    • Identify indications for respiratory (sputum) and blood cultures
    • Describe the clinical decision support tools of Pneumonia Severity Index and CURB-65

    VIEW PRESENTATION

     

    Presenter: Marianne Ries, M.D., M.B.A., CPE, Physician Advisor, Institute for Population Health and Care Transitions Management

     

  • Pulmonary Embolism

    Objectives: Upon completion of this activity, the participants should be able to:

    • Identify strong probability risk factors for pulmonary embolus
    • Describe ECG findings that occur with a pulmonary embolus
    • Identify the most common signs and symptoms of pulmonary embolus

    VIEW PRESENTATION

     

    Presenter: Marianne Ries, M.D., M.B.A., CPE, Physician Advisor, Institute for Population Health and Care Transitions Management

     

  • Sepsis

    Objectives: Upon completion of this activity, the participants should be able to:

    • Identify the key elements required to make a diagnosis of Sepsis, Severe Sepsis, and Septic Shock
    • Review documentation requirements for Sepsis that identify a presumed, suspected, or known source of infection and tie the key SIRS indicators to that source of infection

    VIEW PRESENTATION

     

    Presenter: Marianne Ries, M.D., M.B.A., CPE, Physician Advisor, Institute for Population Health and Care Transitions Management

     

  • Syncope

    Objectives: Upon completion of this activity, the participants should be able to:

    • Describe the definition of Syncope, according to the American Heart Association
    • Identify the 3 most common categories of cause of Syncope
    • Identify and describe the most common risk stratification rules

    VIEW PRESENTATION

     

    Presenter: Marianne Ries, M.D., M.B.A., CPE, Physician Advisor, Institute for Population Health and Care Transitions Management

     

  • TIA and Stroke

    Objectives: Upon completion of this activity, the participants should be able to:

    • Identify other diagnoses that mimic a Transient Ischemic Attack
    • Describe the factors assessed in a NIH Stroke Score
    • Describe the National Stroke Association’s ABCD2 score

    VIEW PRESENTATION

     

    Presenter: Marianne Ries, M.D., M.B.A., CPE, Physician Advisor, Institute for Population Health and Care Transitions Management

     

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Instructions for Claiming Credit

  1. Go to https://cmetracker.net/THR
  2. On the left navigation, click on sign in
  3. Enter your email address and password
    a. If you forgot your password, click the forgot password button
    b. If this is your first time to sign in, click create account
    c. The first time you sign in, you will need to complete your profile
  4. Once you are signed in, go to the Online Activities on the left navigation and select Clinical Documentation.  Find the Clinical Documentation activity you listened to and click the blue Register Button
  5. A registration form will open.  Under Process Registration, click the blue Submit button.  This will open a registration confirmation page.  Click the blue Begin Activity button.
  6. Complete the following modules:  Requirements for Credit, Activity Details, Attestation, Take & Pass Quiz, Complete CME Activity.  Once you click Complete CME Activity, a page will open for you to take an evaluation and claim credit.  Once you claim credit, your certificate will open.  You can save or print your certificate.

If you have questions or need help, please email THRJA@TexasHealth.org

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