chest pain

Unknown
edited May 2016 in CDI Talk Archive
Good morning - inspired by the recent CDI Talk regarding the clarification of 'chest pain', I checked out the Forms and Tools Library on ACDIS and did not see any examples for chest pain. Is anyone willing to share their current form?

Thanks,


Linnea Thennes, RN, BS, CCDS

Clinical Documentation Specialist

Clinical Resource Management

Northwest Community Hospital

847.618-3089

lthennes@nch.org


Comments

  • robert.hodges2robert.hodges2
    edited May 2016
    Here you go.



    Robert



    Robert S. Hodges, BSN, MSN, RN

    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



    "Anyone who has never made a mistake has never tried anything new."
    -Albert Einstein




  • Unknown
    edited May 2016
    Can you send the attachment in a different format? I cannot open it.
    Thanks!



    Virginia Bailey RN, CCDS

    Certified Clinical Documentation Specialist

    Morton Plant Northbay Hospital

    727-859-4880 or ext 74880 from within system




  • robert.hodges2robert.hodges2
    edited May 2016
    Here it is converted back to an older word format. Hope it still is
    intact.



    Robert



    Robert S. Hodges, BSN, MSN, RN

    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



    "Anyone who has never made a mistake has never tried anything new."
    -Albert Einstein




  • Unknown
    edited May 2016
    Thanks! It was fine.



    Virginia Bailey RN, CCDS

    Certified Clinical Documentation Specialist

    Morton Plant Northbay Hospital

    727-859-4880 or ext 74880 from within system




  • davisd2davisd2
    Hi, my queries are not as inclusive as Roberts. We follow the same format no matter what we are asking. Basically we ask for "their opinion", if they are treating for "angina" or "CAD w angina" or whatever diagnosis we are shooting for based on the clinical data, but only one diagnosis is listed on the query. We then list the s/s, treatment they have received, and risk factors. Then at the bottom of the sheet we list the diagnosis we are asking for again, give them box for other explanation, and one for unable to determine (I hate when they check that box)and of course ask them to document in prog notes and d/c sum.
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