RE: [MARKETING] [EXTERNAL] feedback please
A couple of things. First the providers should have continued to document it even when resolved. After all, it was treated and the patient spent time in ICU for it. Second, if the coder did not code it that means they didn't review the entire record and probably only the discharge summary. They really should have looked for it and then queried if they couldn't code it based on the documentation they had available.
A case where the documentation did support the resources, but no continuity in documentation occurred. Perhaps also an opportunity to provide education to the physician who did the discharge summary on the importance to include everything treated during the course of the encounter.
Robert
Robert S. Hodges, MSN, BSN, RN, CCDS
Clinical Documentation Improvement Specialist
VHA CDI Council Member
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley
A case where the documentation did support the resources, but no continuity in documentation occurred. Perhaps also an opportunity to provide education to the physician who did the discharge summary on the importance to include everything treated during the course of the encounter.
Robert
Robert S. Hodges, MSN, BSN, RN, CCDS
Clinical Documentation Improvement Specialist
VHA CDI Council Member
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley