query help
Hi all,
I need some quick help with drafting a query. I have a patient that presented with a ruptured AAA, went to the OR for repair and expired during the procedure. Documentation is sparse likely due to the short LOS. There is no CC/MCC on the record as it stands. I would like to query for Hemorrhagic shock/ABL anemia and I would like to provide options for the MD but want to make sure I am compliant in offering ‘all reasonable options’.
This is what I have currently:
Pt diagnosed with Ruptured abdominal aortic aneurysm in ED per H&P.
“transferred to the operating room hemodynamically unstable with a pressure in the 70s systolic.†Per OP note.
Hgb/Hct 8.7/27.7 on admission with Multiple units of PRBC provided per transfusion record
Levophed ordered per Medication list.
Can you please clarify if any of the following were monitored, evaluation, and/or treated during this patients admission?
Acute blood loss anemia
Hemorrhagic shock
Acute blood loss anemia with hemorrhagic shock
Other
Unable to determine
What do you think? Am I missing anything?
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 need some quick help with drafting a query. I have a patient that presented with a ruptured AAA, went to the OR for repair and expired during the procedure. Documentation is sparse likely due to the short LOS. There is no CC/MCC on the record as it stands. I would like to query for Hemorrhagic shock/ABL anemia and I would like to provide options for the MD but want to make sure I am compliant in offering ‘all reasonable options’.
This is what I have currently:
Pt diagnosed with Ruptured abdominal aortic aneurysm in ED per H&P.
“transferred to the operating room hemodynamically unstable with a pressure in the 70s systolic.†Per OP note.
Hgb/Hct 8.7/27.7 on admission with Multiple units of PRBC provided per transfusion record
Levophed ordered per Medication list.
Can you please clarify if any of the following were monitored, evaluation, and/or treated during this patients admission?
Acute blood loss anemia
Hemorrhagic shock
Acute blood loss anemia with hemorrhagic shock
Other
Unable to determine
What do you think? Am I missing anything?
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
- hemodynamically unstable with a pressure in the 70s systolic
- Hgb/Hct 8.7/27.7 multiple units of PRBC
- Levophed drip [add supporting B/P if you have them]
i.e.
Not clinically significant
Acute blood loss anemia
Hemorrhagic shock
Acute blood loss anemia with hemorrhagic shock
Other
Unable to determine
Charlene
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