Cancer mets
Hello!
I was wondering if anyone out there has a query or template for a lymph node mets (or bone, brain ect). Too often, our physicians don't document path report findings (or that path comes back after discharge), and we send a query to have them document path report findings. However, recently, though we can see the mets to lymph nodes, the physicians are not documenting that.
Does anyone have a non-leading query? I am concerned about "what" clinical indicators to use and what choices to give for the provider to report the findings.
Thanks in advance!
Juli
Juli Bovard RN CDS
Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
719-4390 (work)
786-2677 (cell)
"No Limit to Better......"
[cid:image001.jpg@01CD00F4.A6334310]
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
I was wondering if anyone out there has a query or template for a lymph node mets (or bone, brain ect). Too often, our physicians don't document path report findings (or that path comes back after discharge), and we send a query to have them document path report findings. However, recently, though we can see the mets to lymph nodes, the physicians are not documenting that.
Does anyone have a non-leading query? I am concerned about "what" clinical indicators to use and what choices to give for the provider to report the findings.
Thanks in advance!
Juli
Juli Bovard RN CDS
Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
719-4390 (work)
786-2677 (cell)
"No Limit to Better......"
[cid:image001.jpg@01CD00F4.A6334310]
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
Comments
This is not specific to Cancer, but we use this query when we have somethin=
g described by the pathologist/radiologist/etc that is not brought into the=
progress notes and/or DC summery. I enter in what kind of report it was (e=
x: CT scan), what it found (Ex: cerebral edema) and then ask what the signi=
ficance was.
I'd be interested in hearing whether this could be considered leading. In g=
eneral, our program is very cautious. Our queries are a part of the medical=
record and we generally don't include the suggested diagnosis anywhere in =
the query unless it is a "check-box" query and then we make sure the other =
options are legitimate. However, we were having issues with dx not being pu=
lled from radiology so I asked Lynne Spryszak from HcPro for guidance and t=
his is what she suggested.
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
Paul Evans, RHIA
*************************************************************
Request for Confirmation
Of Pathology Findings
Dear Physician/PA/NP: ___________________________________________________________________ or other responsible provider:
For accurate coding and severity-of-illness compilation, this query is directed to you. When responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not reported unless an authorized provider indicates their clinical significance.
Thank you, on behalf of [insert name], Vice President of Medical Affairs
The Pathologist has identified on __________ (DATE) the Diagnosis : _____________________________
Please validate this diagnosis.
CDI Specialist/Coder: _________________________________ Date:_____________ Time: _______________
Physician/PA/NP Response:
0 I concur with the Pathology Findings
0 I do not concur with the Pathology Findings
0 Cannot be determined
0 No clinical significance:
0 Other/Clarification of findings:____________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Physician/PA/NP Printed Name:____________________________________________________________________
Physician/PA/NP Signature: ___________________________________________Date: __________Time:_______
already in the record and asking if it is clinically significant. I
think the only difference between your query and mine is that I will
enter the results and simply ask if they are clinically significant and
if so can they document to the significance.
It is a nice clean form though. Thanks for sharing J
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"We are dealing with Veterans, not procedures; With their problems, not
ours." --General Omar Bradley
Katy