Need your input please

rmhosler1

Hi everyone:

I have a scenario.

Surgical patient
hgb 9.7 on admission no hx of anemia
EBL 50 cc
hgb dropped to 7.9 2 days after surg 2 U PRBC given. repeat hgb 10.
received about 1500cc IVF
no report of complications in OR report

Would you query in this situation? I did not. Do you agree or
disagree? If you disagree, please tell me what you would have done.


I really appreciate your help!!




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

kerryseekircher

I would query to clarify the cause of the drop in hgb as it appears it was treated through transfusion and monitored with follow up labs.
Kerry Seekircher, RN, CCDS, CDIP
Documentation Specialist Supervisor
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013

mark.dominesey

This is a perfect example to show that we are interested in the completeness and accuracy of the record, more so than picking up a CC. I would suggest as Robert, Greta, and Kerry did in querying for the diagnosis to go along with the change in clinical presentation requiring the treatment of 2 units.
Mark

Mark N. Dominesey, MBA, RN, CCDS, CDIP, CHTS-CP
Director, Auditing & CDI Services
Office: 202.489.4662
Fax: 888.661.7790
Mark.Dominesey@TrustHCS.com
www.TrustHCS.com

rmhosler1

Thank you everyone!!



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

angelisa.romanello

Hello Mary,
I would not query for several reasons:
EBL was 50cc.
No complications
The hemoglobin dropped less than 2 gram.
However some of the other factors I would review include: what type of surgery ? Orthopedic surgeries tend to be wet and the patients receive large volumes of fluids. I would wait another day to see if the hemoglobin remains stable.
Secondly, is there any evidence of hypotension, tachycardia or possibly dizziness? If there was consistent notation of hypotension or weakness of the patient being able to participate in ADLs or therapy, then I would change my mind and query.
I hope that helps.
Lisa


Lisa Romanello, RN,BSN,FNS,CCDS
Manager, Clinical Documentation Improvement
Quality and Compliance
CJW Medical Center
804-228-6527
Angelisa.Romanello@HCAHealthcare.com

rmhosler1

I guess I missed the boat on that one. What if they answered ABLA? How
would you justify that to a RAC reviewer?

Appreciate everyone's input. I am just trying to make sense in my mind.
This is a new rotation for me.





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

renmeyer@sbcglobal.net

According to the 2012 CDI pocket guide, "Documentation by the physician of anemia due to blood loss is definitive - not the amount of blood loss, arbitrary lab values or whether or not a transfusion was given".
Don't know if it is the same in the updated version.
Hope this helps.
Sincerely,

Ren

rmhosler1

I have to honestly say I have never used that, but I am wondering if one would use that as treatment of a lab result when no other cause is found? Just a guess.





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

katysuegood@gmail.com

'precipitous drop in hematocrit' is an option on our anemia query. Some of our MD's actually document this independently and I have never had feedback from the coderst aht they did not feel it was appropriate for coding. News to me.

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

redjay2

I would have looked for the EBL looked at any pre admission testing if any.
I would have queried for abla .
I don't like to query for abla unless there is more the a 2 gm loss . I also like to see a transfusion.
I follow most surgery ,Ortho, trauma cases. Some times just have to use discretion.

debra.stewart@halifaxregional.com

We would query for the cause of drop in hgb, especially after surgery, with that much drop and it was treated and monitored...yes query for cause is what I would do. Even if you get acute blood loss anemia it can be used. Just my thoughts.
Deb

Debra Stewart RN, BSN
Clinical Documentation Specialist
Sentara/Halifax Regional Hospital
South boston, va. 24592
(434)-517-3317 Work
(434)-222-9884 Cell

redjay2

I agree with your thoughts on this.

Judy Valitutto

redjay2

Love this site.love all the response and how we look at our charts. I hunt discuss and even challenge the docs. I also give out candy to the docs regardless if agree or disagree. Blood loss is always tossed around.