multisystem organ failure
Question: What does one do with the diagnosis of "multisystem organ failure"
Could I / should I ask a broad question asking for delineation of the failing organs or based on clinical indicators address each system separately? The diagnosis of acute renal failure has been documented. The patient is in an acute CML blast crisis. I also have a diagnosis of 'presumed DIC'. There are indicators for sepsis and pneumonia is a 'possible' diagnosis. ABG's were done: C02 31, PO2 56 with a sat of 88.8%. The patient was made comfort care only.
Any thoughts?
Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Quality Resources
Menorah Medical Center
Could I / should I ask a broad question asking for delineation of the failing organs or based on clinical indicators address each system separately? The diagnosis of acute renal failure has been documented. The patient is in an acute CML blast crisis. I also have a diagnosis of 'presumed DIC'. There are indicators for sepsis and pneumonia is a 'possible' diagnosis. ABG's were done: C02 31, PO2 56 with a sat of 88.8%. The patient was made comfort care only.
Any thoughts?
Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Quality Resources
Menorah Medical Center
Comments
is a complex patient with a lot going on, but if they don't document it
and make the links between conditions then the severity/mortality scores
may not accurately represent the patient's condition. CML patients (if
I recall correctly from my first 2 years in nursing working a
hematology/oncology floor) in blast crisis are also usually hit with a
lot of chemotherapy which, if that did happen may also be a contributing
factor.
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
"We are continually faced by great opportunities brilliantly disguised
as insolvable problems." Benjamin Franklin
Laurie L. Prescott RN, MSN CCDS
lprescott@morehead.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
I sure like the choices 'acute. . . .'
Do you fit the clinical indicators in on the form somewhere to make sure the support for a diagnosis is there?
Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Quality Resources
Menorah Medical Center
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