query template=hypertensive heart disease

Good morning-
I need some help! Am I asking the right question in the query template below? And do you have suggestions for additional options for responses to avoid being leading? We are not using this yet; it's just a rough draft : )
If appropriate, when clarified, hypertensive heart disease becomes the PDX and the acute CHF (diastolic/systolic) exacerbation is the MCC.
Thanks,
Kerry

Template:
Based on evidence in the medical record, a query has been generated to further clarify documentation.

The diagnoses of CHF, CKD and HTN have been documented in the medical record. To accurately reflect the severity of illness of the patient you are treating; please clarify if the CHF is known or suspected to be due to:


* Hypertensive heart and kidney disease
* Cardiorenal syndrome
* Other_______________
* Unable to determine
* N/A

CLINICAL INDICATORS:
RISK FACTORS:
TREATMENT:

If appropriate, please document in the comprehensive plan of care or progress notes and discharge summary. This form is not a part of the medical record.
Thank you for your clarification on this documentation.

Kerry Seekircher, RN, BS, CCDS, CDIP
Clinical 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

Comments

  • edited April 2016
    Some of the options we have included are ischemic, valvular, and idiopathic as well.

    Alicia Mitchell RN, MSN, CCDS
    Clinical Documentation Specialist
    Norton Healthcare
    502-629-6158 office
    502-259-8548 cell
  • Correct me if I am wrong, but the most recent query brief clarifies that you can use a yes/no query to establish cause and effect. So I would phrase it that way.

    Thanks!

    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'd be careful with inclusion of "cardiorenal syndrom" -- it is
    synonymous with htn hrt/ckd in the coding world but NOT synonymous
    clinically. Clinicians may use the term cardiorenal syndrom to describe
    what coding intends for htn hrt/ckd disease AS WELL AS the scenario
    where acute CHF has tipped a pt into AKI.

    Since coding assumes the link between htn & ckd, better to focus (and
    not confuse the provider) ONLY on the relationship of htn & HF -- don't
    need to include any mention or multiple choice option that includes CKD.
    Really need to include in your query model the prompt/space for
    indicators (some, none or all of which might be present, and off the top
    of my head include-- LVH, absence of hx for ischemic dz/CAD, long
    standing htn, poorly controlled htn, preserved EF, echo results, etc).

    If there is both ischemic/CAD as well as htn, build options to indicate
    htn hrt dz, ischemic dz and BOTH.

    I agree with Katy, yes/no to establish cause/effect is an option.
    A caution -- make sure that the body of the query only includes
    existing dx's in the record (ie, htn hrt dz would NOT be included in the
    body of the question).

    Don

    Donald A. Butler, RN, BSN
    Manager, Clinical Documentation Advisor Program
    Vidant Health, Greenville NC
    DButler@vidanthealth.com ( mailto:mDButler@vidanthealth.com )
  • edited April 2016
    Thank you all so much! I appreciate your feedback/comments/advice always.

    Kerry
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