Committment Issues... How to Query?
I need a fresh new Query idea!
I have 3-4 physicians who have trouble committing to ONE Diagnosis. I realize that sometimes there may be more than one diagnosis which is being treated, but that is not the case here.
They will list several (I'm looking at 5 different diagnoses from a certain Neurologist for a patient admitted with "Dizziness" - "It could be this"; "It could be that")and I have a hard time pinning them down to ONE. It's very frustrating to code!
I suppose it could be considered a "rule-out" situation. I have used "rule-out" queries to try to capture this info. Maybe I haven't constructed the query "quite right"?
I've spoken to them regarding how confusing it can be to code these situations - because sometimes we end up having to code a symptom and list all the possibles underneath as SDx. That's not good - unless it is appropriate.
At this time I've been listing all the possible diagnoses documented in the chart and asking them to please document the Diagnosis/Diagnoses which captures the overall reason for the patient's admission It has had "some" success but wondered if someone has had a "light-bulb" moment query which could be shared.
I would appreciate any ideas which have assisted you in the area.
Thank you,
Norma T. Brunson, RHIA,CDIP,CCS,CCDS
I have 3-4 physicians who have trouble committing to ONE Diagnosis. I realize that sometimes there may be more than one diagnosis which is being treated, but that is not the case here.
They will list several (I'm looking at 5 different diagnoses from a certain Neurologist for a patient admitted with "Dizziness" - "It could be this"; "It could be that")and I have a hard time pinning them down to ONE. It's very frustrating to code!
I suppose it could be considered a "rule-out" situation. I have used "rule-out" queries to try to capture this info. Maybe I haven't constructed the query "quite right"?
I've spoken to them regarding how confusing it can be to code these situations - because sometimes we end up having to code a symptom and list all the possibles underneath as SDx. That's not good - unless it is appropriate.
At this time I've been listing all the possible diagnoses documented in the chart and asking them to please document the Diagnosis/Diagnoses which captures the overall reason for the patient's admission It has had "some" success but wondered if someone has had a "light-bulb" moment query which could be shared.
I would appreciate any ideas which have assisted you in the area.
Thank you,
Norma T. Brunson, RHIA,CDIP,CCS,CCDS
Comments
For those that are hospitalists, we luckily find that their peers "clean up" after them, and I think they have applied peer pressure after our numerous complaints.
Frankly, I think it is a sign of insecurity! How can treatment be delivered appropriately if the assessment can't reach some viable conclusion(s).
Kim
Kim Digardi, RN
Documentation Integrity Specialist
St. Helena Hospital
10 Woodland Road
St. Helena, CA 94574
Phone: 707.967.5936
Email: digardsk@ah.org