The Conundrum of Kidney Disease

摘要

According to the Association of Clinical Documentation Integrity Specialists (ACDIS)1, "the H&P provides concise information regarding a patient's history and exam findings at the time of admission, and it outlines the plan for addressing the issues that prompted the admission."Discussing specific symptoms and signs related to kidney disease found in the history and physical (H&P) is beneficial and vital when conducting a medical record review. Reviewing the H&P is essential in outlining the plan for addressing the issues that prompted this admission. CDI professionals need to see and compare how the chief complaint contrasts with the diagnosis or how it relates to the principal diagnosis.