MI query

dvitalone1dvitalone1
in CDI Talk Archive
Does anyone have a query which asks if the patient had an MI in a compliant manner? I am having writers block on how to word the query.
The record has ACS/UA documented along with elevated troponins and an angiogram which showed blocked arteries with the most being 95%.
Thank you for your help


Dawn M. Vitalone, RN, CCDS
Clinical Documentation Improvement Specialist
Community Hospital

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Comments

  • Unknown
    edited April 2016
    Based on these clinical indicators (elevated troponin 05/05, 06, angiogram showed ________, progress notes 05/05 & 06 indicate unstable angina and ACS) and on your clinical judgment can you further specify the type and acuity of this patients unstable angina? i.e. unstable angina, acute coronary syndrome, nonSTEMI, STEMI, acute MI, [whatever you want to include] other more appropriate diagnosis


    Or something to that effect.


    Charlene

  • singwm@chc.netsingwm@chc.net
    edited April 2016
    Can MI/STEMI/NSTEMI even be introduced as an option on a compliant query since MI was never mentioned in the physician documentation initially ( just ACS/USA)?

    Thank you

    Bill Singletary, RN, BSN, BA, MBM
    Director of Care Coordination / CDI
    Stroke Program Coordinator
    The Medical Center
    250 Park St.
    Bowling Green, KY. 42101
    (270) 796-2554
    singwm@chc.net

  • dvitalone1dvitalone1
    edited April 2016
    Yes you can, as long as the diagnoses are in the same body system

  • Unknown
    edited April 2016
    Based on the AHIMA Guidelines for Achieving a Compliant Query Practice the generation of a query should be considered when the health record documentation:

    - is conflicting, imprecise, incomplete, illegible, ambiguous or inconsistent documentation
    - describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis
    - includes clinical indicators, diagnostic evaluation, &/or treatment not related to a specific condition or procedure
    - provides a diagnosis without underlying clinical validation
    - Is unclear for present on admission indicator assignment


    My thought:
    If the clinical indicators are present query for the diagnosis. If your facility provides options include a range i.e. chest pain, ACS, MI etc. On occasions where there are not many valid options I will include 'not clinically significant' as we do not want to lead a physician to one particular diagnosis.


    Charlene
  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited April 2016
    Agree Charlene.

    The other commenter that qualified as "in the same body system" -- disagree. As long as the clinical indicators, treatment, monitoring, etc. are clearly supportive of the diagnosis, there is no need to only introduce a 'new' diagnosis that is in the same body system (I presume of an existing dx).

    To belabor the point -- a new diagnosis should not be included in the BODY of the question, but is perfectly acceptable to include as part of a multiple choice menu.

    Another point, when there truly are not other clinically reasonable options, I believe it acceptable to only have the diagnosis along with Other____ , clinically not significant, clinically indeterminable, etc. The KEY reason for those additional options is to allow the physician to freely introduce his own option for diagnosis and/or to say 'no'

    Don


    Donald A. Butler, RN, BSN
    Manager, Clinical Documentation Advisor Program
    Vidant Health, Greenville NC
    DButler@vidanthealth.com
    ===========
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