condition being treated but not documented
Can anyone help me?
I have a situation where symptoms of sepsis on admission were present.
Condition was treated. Query was generated. Coding does not want to
forward query as it was never documented in the chart.
Wondering if anyone has any supporting documents regarding this
situation? It seems AHIMA did a recent publication in conjunction with
CDS and this area was mentioned. Can anyone send me an electronic copy
or any other supporting documents you may have that you have found
helpful for this area?
Thanks in advance to all who respond.
Mary A Hosler MSN, RN
Clinical Documentation Specialist
Alumnus CCRN
McLaren Bay Region
1900 Columbus Ave.
Bay City, Michigan 48708
(989) 891-8072
mary.hosler@mclaren.org
"The difference between the right word and the almost right word is the
difference between lightning and the lightning bug."- Samuel "Mark
Twain" Clemens
Comments
I think the February 2013 AHIMA Practice Brief may answer your question and help with your coders. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050018.hcsp?dDocName=bok1_050018
"Multiple choice query formats should include clinically significant and reasonable options as supported by clinical indicators in the health record, recognizing that there may be only one reasonable option. As such, providing a new diagnosis as an option in a multiple choice list-as supported and substantiated by referenced clinical indicators from the health record-is not introducing new information."
"In such circumstances, open-ended or multiple choice query formats must be used. It is not considered leading to include a new diagnosis as part of a multiple choice format when supported by clinical indicators"
I hope this helps.
Mary Lindenboom, RN, BSN, CCDS
Clinical Documentation Specialist
Flagler Hospital
400 Health Park Blvd.
St. Augustine, FL 32086
(904) 819-4254
We have the same issue, but are assured by our consultant group (as well as the AHIMA brief)-that this is a reasonable query! There is no difference between this and say, a CXR with infiltrate and giving ABX-where you can tell the doc is treating for PNA. We would write the query for PNA correct?
Seems to me, your query was for an issues that meets ALL of the criteria listed below-which are reasons we query! GOOD LUCK!
--CLINIICAL INDICATORS OF AN UNDOCUMENTED CONDITION
--PRESENT ON ADMIT STATUS
--EVALUATING A DIAGNOSIS
--BEING THERAPEUTICALLY TREATED
--DIAGNOSTICALLY TESTED
--AFFECTING LOS OR RESOURCES
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......"
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"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens