Documenting linkage

catladyrn

H/P states, "gram negative sputum bacilli, also RLL pneumonia, it appears to be."

Do you think that's a sufficient link, or would you query?

Renee

Linda Renee Brown, RN, CCRN, CCDS, CDIP, CCS

robert.hodges2

I'd query but I like the links to be clear.

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

ssalinas

I would query. In my opinion the statement you have below does not link the two sufficiently since there is a coma and the physician uses the word also.

We have this type of documentation often. The docs have explained to me that positive SPUTUM does not necessarily translate into that type of pneumonia since the sputum may not be coming from the lungs and may just be 'spit'. They will call it 'pseudomonas traceobronchitis' and list pneumonia separately. If they state x bacteria tracheobroncitis AND pneumonia, I would code the bacterial pneumonia along with the tracheobronchitis (or bronchitis or whatever is stated).

Lately it seems we almost have to have a mini-BAL or bronch to get the docs to state any type of bacterial pneumonia. Our clarifications/queries do remind the physicians that suspected, presumed ... statements are acceptable.

Sharon Salinas, CCS
Barlow Respiratory Hospital
213-250-4200 Extension 3336