Coding percentages of Burns

donna.kentdonna.kent
in CDI Talk Archive
We just found out that the coders are taking specificty regarding percentages of burns from a document in the chart that is filled out by nursing. There is no MD signature. Is this valid documentation to code from?

Thanks, Donna

Comments

  • mdomineseymdominesey
    edited May 2016
    I am not sure - if it is the same as wounds, the physician has to document the location, but nursing can document the stage. It is best that the physician sign off to validate the nurse's findings, but I am not sure that it is absolutely necessary.

    Area percentage of burns begs for physician validation. I would place queries to get physicians to validate the nurse's documentation until the process can be worked out where the physician signs off on the nurse's assessment.

    Mark


    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
    Sr. Clinical Documentation Improvement Specialist
    Sibley Memorial Hospital
    Information Technology
    5255 Loughboro Rd NW
    Washington DC, 20016-2695
    W: 202.660.6782
    http://www.sibley.org
    mdominesey@sibley.org
  • donna.kentdonna.kent
    edited May 2016
    We have been placing many queries. Docs are getting frustrated with the
    fact that they tend to use sq.cm.calculation as opposed to percentage.
    But then we come to find out that coders are using percentage as
    identified by burn nurses.
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