[BULK] RE: Problem List
We were asked to do this in our facility and we were not reviewing 100%
of charts. When I brought this up, the response was that some were
better than none with the problem list. Something else we ran into was
the floor nurse removing the information we put in. For example, if we
put in Pneumonia because it was documented initially, the floor nurse
would promptly remove it as a non-nursing dx. At the time, it seemed
like the decision-makers were looking to drop the task in the lap of a
supervisor who wouldn't make much noise about it. Were we effective?
On those charts we reviewed, yes. However, the complete issue was never
further addressed so I suspect the true value was never really
obtained.
It helps to have a good leader on behalf of the CDS who is able to
articulate the value and limitations of the CDS involvement in this
task.
Karen
Karen McKaig, BSN, RN, CCM, CPUR, CCDS
Case Manager
Clinical Documentation Specialist
Baxter Regional Medical Center
Mountain Home, AR 72653
870-508-1499
kmckaig@baxterregional.org
of charts. When I brought this up, the response was that some were
better than none with the problem list. Something else we ran into was
the floor nurse removing the information we put in. For example, if we
put in Pneumonia because it was documented initially, the floor nurse
would promptly remove it as a non-nursing dx. At the time, it seemed
like the decision-makers were looking to drop the task in the lap of a
supervisor who wouldn't make much noise about it. Were we effective?
On those charts we reviewed, yes. However, the complete issue was never
further addressed so I suspect the true value was never really
obtained.
It helps to have a good leader on behalf of the CDS who is able to
articulate the value and limitations of the CDS involvement in this
task.
Karen
Karen McKaig, BSN, RN, CCM, CPUR, CCDS
Case Manager
Clinical Documentation Specialist
Baxter Regional Medical Center
Mountain Home, AR 72653
870-508-1499
kmckaig@baxterregional.org