PHYSICIAN POCKET CARDS FOR YOUR DOCUMENTATION NEEDS

Please find attached below pocket cards that can be helpful for your documentation needs.  They are by specialty and can be very useful for day to day use.  There are printing instructions below if you choose to want to print.

JATA Nuance CDI Physician Pocket Card (Poster) Instructions

Brief Printing Instructions

Attached you find 9 (Specialty) CDI Physician Pocket Cards 4-Card “Sets” entitled, “CDI Physician Pocket Cards – [Specialty]—Please print these 4-card sets using the “A5” (size) + “Booklet” print options for two cards/page… (This setting will allow you to create a four-page booklet of 4×6 cards when printed back-to-back.) [NOTE: Pages 1-3 will be universal CDI tips for all physicians; Page 4 will be specialty-specific.]

Also you will find a Physician CDI (12) Pocket Card document entitled, “CDI Physician Pocket Cards – Master”—This document is a master set of cards, and you have the Option to print them in multiple ways… [NOTE: Pages 1-3 will be universal CDI tips for all physicians; Page 4-12 will be specialty- specific.]

Option #1: Option #2: Option #3:

You can print each page as an 8×11 sheet to act as a poster in physician areas;
You can print “2-on-1” to have 2 pages/sheet to act as a poster in physician areas; You can print “A6” (size) pages (= ~4”x6” Cards) to serve as individual Pocket Cards;

Special Note: Please, note that these pocket cards (or posters) are simply “Reminder” Cards. They are NOT designed as a physician educational guide for CDI; AND they should NOT be considered a substitute for formal Physician CDI education. They are designed simply as reminder cards for physicians that have been or are being trained in CDI.

Detailed Guidance

There are THREE Pocket Cards that every physician should have, because they cover important CDI diagnoses and tips for all specialties. These three cards cover basic tips and most of the top ten CDI opportunities, except CHF. Medical Necessity: Summarizes key issue on initial documentation, incl. POA/HAC issues;
Never-Miss Dxs: Covers Encephalopathy, Resp./Renal Failure (CKD Stages, AKI Criteria);

SIRS/SEPSIS/Other: Covers SIRS criteria, Non-Infect. SIRS, SOFA (DM, Skin Ulcers, Disabilities);

The remaining NINE Pocket Cards are specialty-specific and would be added to the prior three to create a 4×6 Card-sized “booklet”, with four page faces. Each specialty card emphasizes the CDI importance of documenting nutritional status (BMI, Morbid Obesity, Malnutrition, Cachexia). Hospital CDI leaders should walk specialty group members through each respective pocket card to ensure appropriate use of each card.

Gen. Surgery: Would Dehiscence, Peritonitis, ABLA, Post-Op Dxs, Adhesiolysis, Debridement; Trauma: Arrests/Shock/Arrhythm.s, Brain Compress., C. Edema, Infections, Surg. Issues Above; Anesthesia: Surg. Issues Above, Elective/Prolonged Intubation, Post-Proced. Resp. Issues; Pulmonary: Infection, Pneumonia,COPD/Asthma/Bronch. Exacerb., Anesthesia Issues Above; Gastro: ABLA, Pancreatitis, Cirrhosis, Peritonitis, Enteritis, GI Bleed-Inj. Abscess, Scoping; Medicine: ABLA, C. Edema, Infections, Asp. Pneumo., Use-Abuse-Depend., Anemia, DVT/PE; ED/ICU: Acidosis/Alkalosis, Anemia, Arrests, Dialysis, Infections, Shock, Intubation Issues; Cardio: CP & R/O MI, ACS, Acute/Aborted MI, Arrhythmias, Dem. Ischemia, Shock, CHF; Neuro: Syncope, Epilepsy, Seizures, Stroke/CVA, C. Edema, Infections, Delirium, Dementia;