ACDIS CCDS-O case studies
ACDIS CCDS-O · Put your knowledge to work in context.
The Certified Clinical Documentation Specialist-Outpatient (CCDS-O) is a credential offered by ACDIS for clinical documentation integrity (CDI) professionals who work outside the inpatient setting. Per ACDIS, it "provides a trusted baseline of competency for CDI in the outpatient setting, which includes physician practices, hospital clinics, and the emergency department, among other settings," and it "represents a mark of excellence for CDI professionals operating in outpatient settings, and provides employers with a baseline of competency for existing staff or potential hires." That employer-facing purpose explains who typically pursues it: outpatient CDI specialists and reviewers, coding and revenue cycle staff moving into documentation work, practice and clinic managers who oversee documentation quality, and clinicians or educators who support outpatient query practice. The ACDIS CCDS-O case studies are 5 cases and about 3,586 words.
1Annual Wellness Visit With Competing Chronic Conditions
During a Medicare Advantage annual wellness visit, a 72-year-old woman reports four days of worsening dyspnea, two-pillow orthopnea, and a 4-lb weight gain. Her history includes COPD, heart failure with preserved ejection fraction, stage 3a chronic kidney disease, and type 2 diabetes.
765 words, about 4 min2Supratherapeutic INR in the Anticoagulation Clinic
A 64-year-old man with a mechanical mitral valve on warfarin comes to a hospital-based anticoagulation clinic for routine INR monitoring. His INR is 5.8 (therapeutic range 2.5–3.5).
758 words, about 4 min3Syncope in the Emergency Department
A 58-year-old woman is brought to the emergency department by EMS after a witnessed syncope at a grocery store. She has no prodrome and no incontinence.
684 words, about 3 min4Pneumonia or Bronchitis at Urgent Care
A 34-year-old man presents to an urgent care center with three days of productive cough, fever of 101.8°F, and pleuritic right-sided chest pain. Vital signs: HR 112, RR 22, BP 126/78, SpO2 94% on room air.
684 words, about 3 min5Fever During Chemotherapy in the Oncology Clinic
A 61-year-old woman with stage III colon cancer is seen in the hospital’s outpatient oncology clinic on day 10 after FOLFOX chemotherapy. She reports fatigue and chills.
695 words, about 3 min