acute resp failure
I would appreciate some feedback/assistance on a case.
Have a young child that came in with resp distress, stridor and pt ended
up being trach 'ed after dx'ed (this admission) with subglottic stenosis
and tracheal hemangioma. Physician documented Acute Resp Failure (ACRF)
when pt admitted to PICU after trach placed. Only indicator I see
possible for ACRF is pt was on 60% FiO2 via trach COLLAR after surgery
which was weaned to 30% within few hours and then to RA by next day. I
sent query requesting documentation of clinical indicators for ACRF dx
or to clarify dx that best represents pt's resp status. No vent, no
blood gasses, RR mainly within normal limits for age (few increases,
maybe pain related?). I don't feel ACRF is supported with documentation
as is. Another physician documented in 2 of his daily progress notes
"ACRF due to subglottic stenosis requiring trach" when pt transferred
out to general floor. What do you think? Is this enough?
Claudine Hutchinson RN (CDI)
The Children's Hospital at Saint Francis
chutchinson@saintfrancis.com
Have a young child that came in with resp distress, stridor and pt ended
up being trach 'ed after dx'ed (this admission) with subglottic stenosis
and tracheal hemangioma. Physician documented Acute Resp Failure (ACRF)
when pt admitted to PICU after trach placed. Only indicator I see
possible for ACRF is pt was on 60% FiO2 via trach COLLAR after surgery
which was weaned to 30% within few hours and then to RA by next day. I
sent query requesting documentation of clinical indicators for ACRF dx
or to clarify dx that best represents pt's resp status. No vent, no
blood gasses, RR mainly within normal limits for age (few increases,
maybe pain related?). I don't feel ACRF is supported with documentation
as is. Another physician documented in 2 of his daily progress notes
"ACRF due to subglottic stenosis requiring trach" when pt transferred
out to general floor. What do you think? Is this enough?
Claudine Hutchinson RN (CDI)
The Children's Hospital at Saint Francis
chutchinson@saintfrancis.com
Comments
Claudine Hutchinson RN (CDI)
The Children's Hospital at Saint Francis
chutchinson@saintfrancis.com
Cindy
Greta Goodman, CCDS
Clinical Documentation Improvement Specialist
Health Information Management
Virginia Hospital Center
1701 North George Mason Drive
Arlington, VA 22205
703-558-5336
ggoodman@virginiahospitalcenter.com
[CCDS_pin_1inch]
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
Thanks,
Kerry
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
Claudine Hutchinson RN (CDI)
The Children's Hospital at Saint Francis
chutchinson@saintfrancis.com
I understand WHY you are questioning it. But maybe- I know nothing about pediatrics but...maybe because the child's airway is so small that it is obstructed and is resulting in respiratory failure but treated with the trach the patient is able to recover quickly. so would be justified though quickly resolved. Children recover so quickly to things I imagine peds present a whole new world of learning to view things differently. just thoughts.
http://www.virtualpediatrichospital.org/providers/ElectricAirway/Text/SubStenosis.shtml
It's always fun to hear what other deal with...
Ann
ed up being trach
Claudine Hutchinson RN (CDI)
The Children's Hospital at Saint Francis
chutchinson@saintfrancis.com