Institutes and Services

Price $190.00
Documentation for Everyone



Documentation for Everyone

After completing this activity you will be better able to:

  • Identify documentation requirements and criteria that must be recorded each day in the Progress Notes to establish medical necessity, accurate severity of illness, intensity of service and justification of resource consumption.
  • Identify and utilize the required components of documentation essential to establish medical necessity for admission.
  • Define Present on Admission (POA) diagnoses.
  • List Hospital Acquired Conditions (HAC’s).
  • Communicate physician clinical judgment, medical decision making, and plan of care in the inpatient medical record.
  • Comply with Evaluation and Management (E & M) coding guidelines of each patient encounter by explicit documentation of assessment, clinical impression or diagnoses in the medical record.
  • Recognize the importance of documentation of secondary diagnoses in communicating level of patient care to third party payers.
  • Provide necessary and sufficient documentation in the medical record to support medical necessity for admission or procedure.


This program has been approved for 2 continuing education units for use in fulfilling the educational requirements for the maintenance of the C-CDI credential by the Clinical Documentation Improvement and Integrity Certification Board.

This item is available in the following models

Model Code Retail Weight Information
Documentation For Everyone KODDFE $190.00 0.00