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
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
Alicia Mitchell RN, MSN, CCDS
Clinical Documentation Specialist
Norton Healthcare
502-629-6158 office
502-259-8548 cell
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
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 )
Kerry