abnormal labs with no diagnosis

tkreilingtkreiling
in CDI Talk Archive
How do you handle abnormal labs that the physician never refers to or does not treat? For example, + urine culture, not treated with antibiotics or results may come after the patient goes home. I have been asked to query the times I have seen this, and we will not code the dx if the condition does not meet secondary guidelines, but I was curious what other programs do?
Thanks,
Tara RN, CCDS

Comments

  • annnd2009@gmail.comannnd2009@gmail.com
    edited May 2016
    I would think you could ask for diagnosis associated with...
    Treatment /eval could be ua... Maybe it will bring ti providers
    attention and fir patients best interest them will treat.
    Ann D

  • robert.hodges2robert.hodges2
    edited May 2016
    Rule one is that if it’s not treated why are you querying for it in the first place, especially for a culture that comes back after the patient has been discharged. In that case it shouldn’t wouldn’t impact the care provided. The important piece there is that the results go to the patients primary care provider so appropriate follow up can occur.



    If the results are present during the encounter and not addressed, I will query for the clinical significance of the findings, if any. Positive culture results always get a query. I end up having a good discussion with the hospitalists on the issue and normally they will address it in their notes. However, if they tell me they aren’t treating it and it doesn’t impact the care the patient is receiving, I drop it there and always thank them for their time. The key thing though is to ensure it’s a “significant” finding. Not 0.1 off of normal range, but something that catches your eye beyond just being a little high or low unless it’s a chronic low finding for anemia or chronic kidney disease for example.



    I guess the bottom line is it never hurts to query.



    Robert



    Robert S. Hodges, BSN, MSN, RN, CCDS

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  • lsipos@monument.healthlsipos@monument.health
    edited May 2016
    We would query for "Clinical Signifigance or incidental finding with no signifigance/untreated". Though I do agree with Robert that the issue is a "fine-line" depending upon what the irregularity was. Neither would be monitor this after dc and leave that to follow up care issues...


    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

  • sharon.colesharon.cole
    edited May 2016
    Hi Tara,
    If the patient is still in-house, I will verbally ask about the value or if haven't been able to catch them, will go ahead and place a written query. Sometimes, they are not aware of the abnormal value and will begin treatment after seeing the query. I'm not so much worried about a diagnosis as I am about letting them know there is a potential condition not being addressed.
    If the patient has already been DC'd will still keep a copy of the lab and show them in case it was significant and they need/want to call the patient and order treatment at home.

    Sharon Cole, RN, CCDS
    CDI Specialist
    254.751.4256
    Sharon.cole@phn-waco.org


  • tkreilingtkreiling
    edited May 2016
    Currently we do any retro queries that the coder requests. The coder in this particular case noticed the urine culture results that grew >100,000 k.pneumoniae. The results came back around the same time the patient was being discharged it appears. No treatment was done, no UTI was documented. UA was positive for nitrates though at admission. If I had found this concurrently I would have left a query and hope they start some treatment for the patient. Most of these cases are post discharge though. I have been instructed from a quality standpoint the doctor needs to be asked or notified. I am really just curious if this is something other facilities do.
    Thanks,
    Tara, RN CCDS



  • sharon.colesharon.cole
    edited May 2016
    And yes, I realize post DC treatment/dx will not impact - just want what's best for the patient. Would hate for them to go home and return with a raging UTI

    Sharon Cole, RN, CCDS
    CDI Specialist
    254.751.4256
    Sharon.cole@phn-waco.org


  • tkreilingtkreiling
    edited May 2016
    Thanks, that sounds like what we are doing. Makes me feel a bit better to know someone else would do this also. I was second guessing our practice since it doesn't affect the coding, but you are right it is what is best for the patient. Thanks!



  • rmhosler1rmhosler1
    edited May 2016
    Hello:

    Lots of great information. At our hospital, I contact the nurse caring
    for the patient and she calls the doctor or faxes the result to the Dr.
    office for further followup.

    Mary A. Hosler RN, MSN
    Clinical Documentation Specialist
    McLaren-Bay Region
    1900 Columbus
    Bay City, Michigan 48708
    (989) 891-8072

  • sbeattysbeatty
    edited May 2016
    This is how we handle such cases.

    Sandy Beatty, RN, BSN, CCDS
    Director of Clinical Documentation Improvement
    Community Health Network
    1500 North Ritter Avenue
    Indianapolis, IN 46219
    317-355-2016
    sbeatty@ecommunity.com

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