systolic/diastolic dysfunction

katysuegood@gmail.com

I am wondering how you tackle the issue of documentation of systolic or diastolic dysfunction without documentation of heart failure or CHF. One of the coders just contacted me saying they are seeing an increased incidence of this recently. If you have a query with options/check boxes, what do you include?

Thanks!!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

lsipos@monument.health

Katy

I think it all goes back to "clinical indicators of a condition or diagnosis being treated or using resources but not yet being documented" - at our institution we query for those issues all the time (unfortunately)
Is it-
-evaluating a diagnosis?
-being therapeutically treated?
-diagnostically tested?

We have a standard template query for CHF. Many times we can determine it is "systolic" or "diastolic", but our template has one column for the acuity, and one column for the type...and as always an "other or unable to determine"....
We just input any data, clinical indicators, echo results, medications ect and then ask them "if there is an associated condition related to the results, meds, clinical indicators"

Hope this helps!


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......"


"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens