CHF/CARDIOMYOPATHY
Good morning! Help. I am having problems with a CHF query relative to the TYPE. Pt admitted with CHF exacerbation and Cellulitis. Both being treated equally. BNP >5000, IV Lasix, Echo EF 23%. HX Cardiomyopathy. I electronically queried of course for the type of CHF. On the FIRST query the provider put "acute on chronic chf being treated for the exacerbation, and is secondary to dilated cardiomyopathy. So, I queried again, and explained we needed the "type" diastolic, systolic etc so that we could be most specific. The provider answered on the second query- " Yes, CHF is acute on chronic and secondary to dilated cardiomyopathy. (BOTH queries gave her the options of acute, chronic, acute on chronic, as well as systolic, diastolic and systolic and diastolic-per our standard queries). The provider NEVER answered in the obvious "choice fields" and instead chooses to free type her answers.
I have explained to her the TYPE of CHF relative to a diagnosis, for Cardiomyopathy etc. She will just not answer the query and I don't know what to do. She is an outlier and unfortunately though this is known, I don't know where else to take this. She is the attending. Cardio is on and of course is just saying "CHF" as well. So, do I query cardio? (Cardio is still documenting in the PAPER chart, and generally never answers the queries, but I can try).
Suggestions?
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......"
[CCDS_pin_1inch]
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
I have explained to her the TYPE of CHF relative to a diagnosis, for Cardiomyopathy etc. She will just not answer the query and I don't know what to do. She is an outlier and unfortunately though this is known, I don't know where else to take this. She is the attending. Cardio is on and of course is just saying "CHF" as well. So, do I query cardio? (Cardio is still documenting in the PAPER chart, and generally never answers the queries, but I can try).
Suggestions?
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......"
[CCDS_pin_1inch]
"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
Cindy
If that doesn't work, I would call or try to talk to the physician face to face and use it as an educational. Good Luck!
I know some providers just are not very cooperative.
Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com
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Ann
You may also want to check into who read the echo, because at our hospital they don't want to step on toes between IM and Cardiol.
Good luck!!
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