The Clinical Documentation Improvement specialist at Wildcat Hospital
Description
You are the Clinical Documentation Improvement specialist at Wildcat Hospital. Your CDI team has asked you to create a closed record review checklist for the physical examination completed by the attending physician.
Using Excel or another spreadsheet, I want you to create an audit to analyze the completion of a physical exam. The overall goal is to be able to assess and analyze this audit, so you want your data to have the ability to be aggregated. I recommend students to make each row a yes/no question which covers the timely completion of the physical exam by CMS and The Joint Commission and the required physical exam components.
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Create your audit so it can be used for 5 health records (columns). You do not need to fill in the audit form (marking yes/no), just create the audit The Clinical Documentation Improvement specialist at Wildcat Hospital