We don't have one specifically for post op. We have:
Bowel sounds finding associated with a presumed diagnosis of Ileus Bowel sounds finding without a presumed diagnosis of Ileus Other (please specify): Unable to Determine (please comment):
If it was post op, I would write on our generic:
S/P.....with ileus S/P.....without ileus Other: Unable to Determine (please comment):
We only have one predesigned for if Ileus is documented but we are unsure if it is a complication or expected. To query for the ileus its self I would probably just to a generic clarification form with the signs/symptoms and treatment. This is what we have.
Katy Good, RN, BSN, CCS Clinical Documentation Program Coordinator AHIMA Approved ICD-10CM/PCS Trainer Flagstaff Medical Center Kathryn.Good@nahealth.com Office: 928.214.3864 Cell: 928.814.9404
if writing multiple choice queries for an ileus I would consider the following options which would also clarify if it should be coded as an "ileus" (not a complication) or "post-op ileus" (complication:
- clinically significant ileus related to (or as a result of) surgery - clinically significant ileus unrelated to surgery - ileus: not clinically significant - other finding related to bowel function (please state) - unable to determine
Since ileus is a high-audit diagnosis, the record (and the query) should clearly elucidate/document the resources used, such as: additional length of stay, re-insertion of N/G tube (if present), reversal of diet (clear to NPO, soft to liquid, etc.), repeat x-rays, add'l monitoring, consults ordered, etc.
Comments
Bowel sounds finding associated with a presumed diagnosis of Ileus
Bowel sounds finding without a presumed diagnosis of Ileus
Other (please specify):
Unable to Determine (please comment):
If it was post op, I would write on our generic:
S/P.....with ileus
S/P.....without ileus
Other:
Unable to Determine (please comment):
Jill Lindsey, RN, BSN
Phoenix Children's Hospital
Clinical Documentation Specialist
602-810-4197
Ext. 3-0725
Katy Good, RN, BSN, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Office: 928.214.3864
Cell: 928.814.9404
- clinically significant ileus related to (or as a result of)
surgery
- clinically significant ileus unrelated to surgery
- ileus: not clinically significant
- other finding related to bowel function (please state)
- unable to determine
Since ileus is a high-audit diagnosis, the record (and the query) should clearly elucidate/document the resources used, such as: additional length of stay, re-insertion of N/G tube (if present), reversal of diet (clear to NPO, soft to liquid, etc.), repeat x-rays, add'l monitoring, consults ordered, etc.
This is a DRAFT query I am developing for ileus.
Paul Evans, RHIA, CCS, CCS-P