Question
Hello! Just a quick question. I was trained that "you could not introduce new information into a medical record or query". So my question is, if for example a physician documents CKD in a chart. Can I use PAST labs from other admits (not the current admit) to query for the stage? I know the coders cannot code from labs and or use that info, but can a CDS base a query on old information-ie using GFR as a baseline from a previous stay?
Appreciate your answers.
Juli Bovard RN CDS
Rapid City Regional Hospital
Rapid City, SD
jbovard@regionalhealth.com
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......"
[CCDS_pin_1inch]
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
Appreciate your answers.
Juli Bovard RN CDS
Rapid City Regional Hospital
Rapid City, SD
jbovard@regionalhealth.com
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......"
[CCDS_pin_1inch]
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens