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


Comments

  • Any thoughts/feedback?



    Claudine Hutchinson RN (CDI)

    The Children's Hospital at Saint Francis

    chutchinson@saintfrancis.com



  • edited April 2016
    I think you have enough information in what you already have; especially with the last documentation you shared. I would not query.
    Cindy

  • I would not Query. That seems like enough documentation to support the diagnosis to me.

    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]


  • edited April 2016
    I think the ARF dx is fine. The ARF is caused by the subglottic stenosis and both were treated with a trach.

    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

  • edited April 2016
    I think you should be okay with that dx if child had stridor, resp distress, requiring trach.
    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

  • Thanks everyone! Query cancelled. J



    Claudine Hutchinson RN (CDI)

    The Children's Hospital at Saint Francis

    chutchinson@saintfrancis.com



  • edited April 2016
    Hi,

    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
  • Thanks for the link Ann!!!



    Claudine Hutchinson RN (CDI)

    The Children's Hospital at Saint Francis

    chutchinson@saintfrancis.com


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