RE: anemia

pfowlerpfowler
edited May 2016 in CDI Talk Archive
When your physicians document anemia of chronic disease do you query for
the disease process causing the anemia.

One of our docs likes to document "GI Bleed with anemia" or "anemia d/t
GI Bleed" and when I query for type of anemia he thinks I should know it
is blood loss.. how would you handle these queries?



Patsy Fowler RN, MSN, CCDS

Certified Clinical Documentation Specialist

Marion Regional Medical Center

PO Box 1150

Marion, SC 29571

Office 843-431-2044

Cell 843-431-2863

Fax 843-431-2475




Comments

  • Unknown
    edited May 2016
    I query for more specifics if I think it is due to neoplastic, CKD or blood loss.


  • robert.hodges2robert.hodges2
    edited May 2016
    I normally query for more specificity. In fact if they say anemia due
    to GI blood loss, I will query if the blood loss is acute or chronic.
    I'm with you; a GI bleed does not necessarily indicate that that the
    anemia is due to that. And as we all know, we cannot assume anything or
    assume links in these cases. I'd work to educate the provider,
    especially about not being able to assume links and keep the queries
    going in the mean time.



    Robert



    Robert S. Hodges, BSN, MSN, RN

    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



    "Anyone who has never made a mistake has never tried anything new."
    -Albert Einstein




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