Respiratory failure....
Good morning everyone.
I am second guessing myself on a record and would love some feedback.
I am reviewing the chart of an expired patient. The patient came in with a nonsurvivable brain stem hemorrhage and was only hospitalized for approx 10hrs. We currently have NO CC or MCC on the record. The MD specifically states there is no mass effect or midline shift. No mention of cerebral edema or brain compression. The patient was maintained on the ventilator however the ED note states that he was “intubated for airway protectionâ€. No mention of resp distress, ABG is normal, and he does have spontaneous respirations. Based on this, I was opting not to query on resp failure as I do not see indicators. Then I noticed the ED note does list “respiratory arrest†on the problem list.
Am I right in NOT querying on this record or am I not be aggressive enough?
Thanks in advance!
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
I am second guessing myself on a record and would love some feedback.
I am reviewing the chart of an expired patient. The patient came in with a nonsurvivable brain stem hemorrhage and was only hospitalized for approx 10hrs. We currently have NO CC or MCC on the record. The MD specifically states there is no mass effect or midline shift. No mention of cerebral edema or brain compression. The patient was maintained on the ventilator however the ED note states that he was “intubated for airway protectionâ€. No mention of resp distress, ABG is normal, and he does have spontaneous respirations. Based on this, I was opting not to query on resp failure as I do not see indicators. Then I noticed the ED note does list “respiratory arrest†on the problem list.
Am I right in NOT querying on this record or am I not be aggressive enough?
Thanks in advance!
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
Comments
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
Kim
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
Jill Lindsey, RN, BSN, CCDS
Phoenix Children's Hospital
Clinical Documentation Specialist
Ext. 3-0725
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
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
Thanks for your input. I have heard a lot about how "resp failure" is not supported by documentation such as need for airway protection. Basically my only CI of resp failure is the treatment. But if they are attributing the vent to "airway protection" can I use that as a CI of resp failure?
This will likely be the only MCC on the record (if I did query and get a + response) so I want to make sure it is defensible.
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
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
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley
Robert
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
Sharon Salinas, CCS
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
ssalinas@barlow2000.org
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