query wording

Unknown

I am looking for some suggestions on the wording of a query for a diagnosis without clinical indicators.

What I have (not sure I like):

Documentation in the H&P of the medical record indicates a diagnosis of "AKI". Based on the below listed documentation and clinical indicators could you please provide validation for or invalidate this diagnosis?
H&P: AKI; CKD stage 3
07/09 lab: BUN: 14 creat: 1.0 GFR: 56.4
07/09 ua: protein negative
07/10 lab: BUN: 8 creat: 0.9 GFR: 63.8

Any thoughts out there?


Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Quality Resources
Menorah Medical Center
5721 W. 119th Street |

catladyrn

I would adapt the verbiage right out of the practice brief:

Please review the laboratory section of the present record to confirm or revise your diagnosis of AKI. Laboratory findings indicate a serum creatinine of 1.0 in this patient with previously diagnosed CKD III.

You could slap on the RIFLE or AKIN criteria, too, if you wanted.

Renee

Linda Renee Brown, RN, MA, CCDS, CCS, CDIP

Unknown

Excellent!! Thank-you.


Charlene