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closed record review checklist:physical examination

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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. An example of a closed record review checklist for a discharge summary is found in Chapter 7 on pg 428.

To assist you in finding the requirements for the physical examination, review table 5.2, pages 203-207 in your text, read the AHIMA practice brief Documentation Requirements for the Acute Care Inpatient Record (AHIMA Practice Brief) in module 7 specific to the physical examination. Review the rubric to help you find what elements are required for this assignment.

Assignment: Create a table (Word or Excel) for a closed record review checklist: physical examination.

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