Please reference the UNMH Intranet CDI page for the most updated documentation tip sheets. https://hospitals.health.unm.edu/clinical-documentation/  > Best Practices > Tip Sheets

This is a repository of the UNM HIM CDI & Coding Guidelines to help with documentation:

You can find the most recent updated tip sheets on the UNMH Clinical Documentation Integrity intranet page: https://hospitals.health.unm.edu/clinical-documentation/ 

General Best Practice words summary card: Best Practice Documentation Examples.docx  

New Documentation Policies (4/2023)

• New documentation policies for AKI/CKD and myocardial injury/infarction are posted in UNM Policy Manager. These include approved institutional definitions of common diagnostic terms. Main takeaways are to get away from writing “non-ACS troponin elevation” or “troponinemia,” and instead differentiate ischemic vs. non-ischemic myocardial injuries and use diagnoses in the table screenshot below. In particular, if there’s elevated troponin and ischemic signs or symptoms, that’s a myocardial infarction. If thought to be due to myocardial oxygen supply-demand mismatch, we should call that a type 2 NSTEMI. If non-ischemic, we should call it a myocardial injury. If someone has ischemic signs or symptoms without elevated troponin, that’s either unstable angina (if due to suspected coronary disease) or demand ischemia (if not due to suspected coronary disease but rather another condition that may cause a myocardial supply-demand mismatch).
• The takeaway from the AKI policy is some guidance about when/how to diagnose acute tubular necrosis.

L&D Top Ten Queries:

Top Ten workstation tip sheet