chf vs TACO vs TRALI

tpeytontpeyton
in CDI Talk Archive
I have a 73 yo pt who has severe anemia/gib, hx chf, who during blood transfusion developed dyspnea/cp and cxr shows mild chf.
In your clinical opinions what would you clarify for?

Tracy M. Peyton
tpeyton@brmc.com

Comments

  • mdomineseymdominesey
    edited May 2016
    Well the dyspnea is a symptom of something going on in the lungs, the CXR shows CHF (yes, interpreted as "mild"). I would still place my generic CHF query with the clinical indicators from the chart. I would also look for any reactions to the blood in the record.

    Mark



    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
    Clinical Documentation Excellence
    Sr. Clinical Documentation Improvement Specialist
    Sibley Memorial Hospital
    Information Technology
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  • dvitalone1dvitalone1
    edited May 2016
    I'd also query for anemia specificity
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Are there any other indications of TRALI? Hypotension? Fever?
    I would definitely Query on the specificity for CHF and anemia since that is clearly in the record. You could also query on the underlying cause of the CP/Dyspnea during the transfusion if it is unclear if CHF is the cause. If you have access to the DR, I also think this would be an appropriate time CHF was the cause or whether it was something else.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • robert.hodges2robert.hodges2
    edited May 2016
    If you use a CHF query wouldn't you be leading? Personally I'd use my signs and symptoms query, include the CXR results, and simply ask for the clinical significance, if any, of the signs and symptoms. And if they are clinically significant, ask for the significance and cause of the signs and symptoms to be documented. And as someone else said, I'd also query for specificity of the documented anemia.

    Just my thoughts.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
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  • mdomineseymdominesey
    edited May 2016
    CHF is already documented as hx and now in the CXR report. So fair game IMHO.

    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
    W: 202.660.6782
    F: 202.537.4477
    mdominesey@sibley.org
    http://www.sibley.org
  • tpeytontpeyton
    edited May 2016
    already did the anemia clarification

    Tracy M Peyton RN, CCDS
    Bradford Regional Medical Center
    Upper Allegany Health Systems
    116 Interstate Parkway
    Bradford, PA 16701
    814-558-0406
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Hmm... something magically was cut off in my response. It should say

    "this would be an appropriate time for a quick conversation with the Dr to clarify if CHF was the cause"

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I was going on the assumption that CHF was already documented in the record. If not, I would just query for the underlying cause of the dypsnea/CP.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • tpeytontpeyton
    edited May 2016
    h/p already has ch systolic hf......that is why I was thinking acute.....but wasn't sure with happening during transfusion and transfusion was stopped. Doc unfortunatlely had already made rounds.

    Tracy M Peyton RN, CCDS
    Bradford Regional Medical Center
    Upper Allegany Health Systems
    116 Interstate Parkway
    Bradford, PA 16701
    814-558-0406
  • sharon.cooper@owensborohealth.orgsharon.cooper@owensborohealth.org
    edited May 2016
    Agree


    Sharon Cooper, RN-BC, CCS, CCDS, CDIP
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  • robert.hodges2robert.hodges2
    Because you are unsure of the cause of the symptoms, I would still query on the signs and symptoms and ask for the underlying cause to be documented. It may very well be an acute exacerbation of the CHF related to fluid overload from the transfusion, but it could also be a transfusion reaction. Best for the provider to clarify than assume a cause or lead a provider to a diagnosis.

    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
  • mdomineseymdominesey
    edited May 2016
    There is enough evidence to just query for a clarification of the CHF that is already documented. It is in HX and now documented in the Radiology report. The query would not lead the doc to say that the particular cause of the dyspnea is CHF, merely to ask for a clarification of the non-specific diagnosis that is already documented.

    I would not hesitate to place a CHF query based on this evidence. I would also place an additional query asking for a cause and effect of the current problem with acute CHF being but one option with "None" and "Unable to determine" being additional options.

    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
    W: 202.660.6782
    F: 202.537.4477
    mdominesey@sibley.org
    http://www.sibley.org
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Agree - asking attending to comment on the CHF noted in Rad report should be acceptable. Rule in - rule out - state other cause - unable to determine - no CHF, no overload - other acceptable responses ensuring compliant query.



    Request for Clarification or Confirmation Of Radiology Findings


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    Physician/PA/NP Response:

    CONFIRMATION:

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