Help

Help! I am reviewing a patient this morning where the physician has documented;
"SIRS-PT CXR AND UA ARE UNREMRAKABLE. BLOOD CX SENT. THIS IS BEING BLAMED ON ACUTE GASTROENTERITIS. PT REPORTS EATING A FROZEN PIZZA A FEW HOURS BEFORE THE DIARRHEA STARTED. WE HAVE THE PT ON CIPRO AND FLAGYL AND WILL MONITOR..." ( Yes, really).

I don't even know where to start to write a query for this. Bacterial? Food poisoning? Are you treating a specific pathogen with the Cipro and flagyl??
Suggestions??? I looked in ACDIS under forms and tools and didn't really find anything to lead me to a good query or verbiage to use that would be appropriate....

Thanks in advance

Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
719-4390 (work)
786-2677 (cell)
"No Limit to Better......"
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"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens





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