Anesthesia Record

kmcdiarm@nhs-healthlink.orgkmcdiarm@nhs-healthlink.org
in CDI Talk Archive
Hi All,

I am wondering how others use the diagnoses that are documented on a patient's anesthesia record (AR). Do you use them as you would a consultant's note or do you query the attending to have a diagnosis carried into the body of the medical record? Wondering what best practice is in this case.

Thanks,
Kathy

Comments

  • Unknown
    edited May 2016
    We use them as SDx's


    Charlene

  • mdomineseymdominesey
    edited May 2016
    I agree that the anesthesiologist's documentation can be treated as a consultant's documentation meaning that you can code as is, as long as there is no conflict with what is previously documented. That being said, my opinion that it is best practice to at least have a chat (verbal query) with the attending/discharging physician to get them to mention the diagnosis in their progress or DC summary.

    One would hate to lose an entire case on RAC review because of a diagnosis written by the anesthesiologist that is not really supported in the body of the record.

    Regards,

    Mark


    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
    Sr. Clinical Documentation Improvement Specialist
    Sibley Memorial Hospital

    Information Technology
    5255 Loughboro Rd NW
    Washington DC, 20016-2695

    W: 202.660.6782
    F: 202.537.4477


    http://www.sibley.org


  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    No need to query for confirmation of condition stated as per Anesthesia

    Reference:

    AHA Coding Clinic
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