Transcription of CDI “GOLDEN RULES”
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cdi golden rules Please write legibly (unusable by anyone for anything if illegible!!) Please use the problem specific approach for all charting Please dictate all H&Ps, consultations, procedure notes, operative reports, and discharge summaries ON THE DAY OF SERVICE to the patient Please list ALL Diagnoses in D/C summary - Particularly CDI Queried Diagnoses! Please pay attention to CDS nurse queries - They are here to help you! Remember Present On Admission if an unrealized problem is discovered or realized later on in hospitalization and was present at admission Please write out all arrhythmia names and all hypo- or hyper- electrolyte -emias Consider alternative descriptors to labeling disease processes as post-op Do not use symbols and/or arrows to describe disease processes Possible, probable, suspect, likely, etc. OK w/ CMS but must be in D/C summary Acidosis - pH < , pCO2>45, HCO3<18, anion gap >12 Alkalosis - pH > , pCO2<28, HCO3>28 Acute Encephalopathy Definition: Global cerebral dysfunction in absence of structural brain disease.
CDI “GOLDEN RULES” Please write legibly (unusable by anyone for anything if illegible!!) Please use the “problem specific” approach for all charting
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