to query or not to query

cmclose@saintfrancis.comcmclose@saintfrancis.com
edited May 2016 in Pediatrics
Need some input. Have a child admitted to Trauma team after horse fell
on her. C/o Abd pain, had hemoperitoneum, ischemic bowel, resection
done, pt admitted to PICU after surgery. Creat=1.3 on admit (ER
arrival); received IVF's, had a foley, TPN profiles ordered. Creat
decreased to 0.6 then 0.58 (on day 1 and day 2 respectively). UOP 134ml
in 8hours after admit to PICU per nursing I&O documentation, pt wt=31kg
(so UOP=0.54ml/kg/hour). Would you query for Acute Renal Failure/Acute
Kidney Injury???? No mention of it in record. BUN was normal.
Thanks for any advice!

Claudine Hutchinson RN
Clinical Documentation Improvement Specialist
Children's Hospital at Saint Francis
Email: chutchinson@saintfrancis.com
Office: (918) 502-6603
Pager: 98-1001


Comments

  • mdomineseymdominesey
    edited May 2016
    Well the creatinine bump could very well have occurred because of traumatic injury to the Kidney - the child had pneumoperitoneum, so compression of circulation to kidney possible - even outright compression of the kidney possible.

    Children have operationally a better chance of recovering creatinine clearance faster than older people, even with an acute traumatic kidney injury. My opinion is that the query would be valid, but unless you see any resources directed to its treatment, it is not really appropriate to report as a secondary diagnosis.

    Mark



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

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

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    F: 202.537.4477
    mdominesey@sibley.org

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