Coding from ER sheet

dwinkdwink
edited May 2016 in CDI Talk Archive
If there is more specifically in the ER T-sheet then there is from the Attending's documentation, can you use the ED note for more specificity? (i.e. both physicians documents pneumonia, but the ER physicians states Aspiration pneumonia). Thanks


Debbie Wink, BS, CPC, CDS

Clinical Documentation Specialist

Clinical Quality Management

Phone: 573-458-7716

E-mail: dwink@pcrmc.com

Comments

  • catladyrncatladyrn
    If the attending doesn't pick up the diagnosis of aspiration pneumonia, I wouldn't either, at least not without a query. The ED doc's findings are almost always very preliminary (with some exceptions such as acute respiratory failure when they intubate in the ED), and should be generally confirmed by the attending, IMO. OTOH, if you do have clinical evidence of aspiration pneumonia that just isn't being documented, you could use the ED doc's note as supporting documentation for the query.

    Renee

    Linda Renee Brown, RN, CCRN, CCDS
    Senior Consultant, CDI/Nursing
    Jacobus Consulting, Inc.
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