feedback please
Hi,
I have a case I would like some feedback on.
The patient was transferred from a rehab facility for "hematuria and flu like symptoms."
The H&P states severe sepsis - sepsis criteria is met. The patient is in ICU for several days and the ICU physicians document sepsis and then sepsis resolved. Sepsis is no longer mentioned in the notes, and the discharge summary (by another physician) says patient was treated for hematuria and the flu.
Am I mistaken in thinking that sepsis should have been coded, or queried for by the coder?
Thanks so much in advance!
Vanessa Falkoff RN
Clinical Documentation Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
Compassion * Accountability * Respect * Integrity
I have a case I would like some feedback on.
The patient was transferred from a rehab facility for "hematuria and flu like symptoms."
The H&P states severe sepsis - sepsis criteria is met. The patient is in ICU for several days and the ICU physicians document sepsis and then sepsis resolved. Sepsis is no longer mentioned in the notes, and the discharge summary (by another physician) says patient was treated for hematuria and the flu.
Am I mistaken in thinking that sepsis should have been coded, or queried for by the coder?
Thanks so much in advance!
Vanessa Falkoff RN
Clinical Documentation Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
Compassion * Accountability * Respect * Integrity