hemiparesis/hemiplegia

tkreilingtkreiling
in CDI Talk Archive
I need some help coming up with a non-leading query to clarify a CVA with left sided weakness. Can I ask to further clarify if weakness is hemiparesis or hemiplegia without that being considered leading? Not sure how else to do it, but always thought I could not bring in a new diagnosis that had not already been written? Any suggestions?
Thank you,
Tara

Comments

  • megan.bartonmegan.barton
    edited May 2016
    "Weakness" is a symptom. Please clarify if there is a diagnosis related to this symptom.


    Megan Barton RN, BSN
    Manager Clinical Documentation Improvement
    Health Information Management-Mercy East
    Ph: 314-251-6192
    Fx: 314-251-3982
  • robert.hodges2robert.hodges2
    edited May 2016
    I agree. Asking them to further specify the severity of the weakness and you could even include hemiparesis and hemiplegia as options as well as if it is to the dominant vs. non-dominant side will all make a difference. Just make sure you offer an "other" and "unable to determine" choice in your query to ensure its not leading.

    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
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    “Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge
  • yuliyafishyuliyafish
    edited May 2016
    Attached is the one we use. We do not query for dominant side, now I
    am wondering if we should start. What do you guys think?

    Yuliya Fish, RN, CCDS
    CDI-S
  • robert.hodges2robert.hodges2
    The VA has two standard query forms. One for acute CVA and the other for late effects of CVA. Both request that the documentation include, as appropriate, if the dominant vs. non-dominant side is affected. Our neurologist will always document if the person is right or left handed which makes this easy to figure out, but most providers don't document that.

    Getting the specificity does change the codes being assigned . Just something to think about.

    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
  • tkreilingtkreiling
    edited May 2016
    Thanks for sharing.

    Tara
Sign In or Register to comment.