Clinical Documentation Integrity
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

    View Presentation

    2-Midnight Rule Tip Sheet

    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

    View Presentation

    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

    View Presentation

    Acute Kidney Injury Tip Sheet

    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

    View Presentation

    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

    View Presentation

    Anemia Tip Sheet

    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

    View Presentation

    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

  • 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

    View Presentation

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

  • Failure to Thrive (FTT)

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

    • Recognize distinct criteria for frailty and adult failure to thrive
    • Discuss the interdependence of frailty and adult failure to thrive
    • Describe the documentation requirements for frailty and failure to thrive
    • Recognize the parts of frailty and failure to thrive diagnoses that may be delegated

    View Presentation

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

  • 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

    Observation vs. Inpatient Tip Sheet

    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://ce.texashealth.org
  2. In the search box, type in clinical documentation and click search. Select the clinical documentation course you want to take.
  3. Click on the Register/Take Course tab and either log in or register to take this course.
  4. Once you log in or register, you will see a blue TAKE COURSE button. Click on this button.
  5. On the left side you will see your course progress.
    1. Activity Details – Click the blue START button.  View the activity details.
    2. View Presentation – Click the blue START button. This will give you the link to take the course.
    3. Attestation – Click the blue START button. Then click the blue Start Quiz button.  Read the attestation question, choose your answer and click the blue FINISH button.
    4. Post-Quiz – Click the blue START button. Then click the blue Start Quiz button.  Answer the questions and click the blue FINISH button.
    5. Evaluation – Click the blue START button. Complete the evaluation.
    6. Credit – Click the blue START button. Select the type of credit and enter the amount of credit claimed.
    7. Certificate – Click the blue START button. Download your certificate.
    8. You completed the course.

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

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