Appreciate any information for Neonatology Project
I am creating a power point presentation on “NICU Documentation†for the neonatologists at my hospital. The physicians have expressed an interest in improving their clinical documentation. I do not have a background in Neonatology and would appreciate any information/resources that you could share with me on the subject.
I would like to know what the most common major diagnoses are;
What diagnoses DO and DO NOT impact the ROM/SOI but are documented in the record
Thank you,
Regina McCroskey, BSN CDS
Cypress Fairbanks Medical Center
Houston, Texas 77065
Regina.McCroskey@tenethealth.com
Phone: 281.897.3146
I would like to know what the most common major diagnoses are;
What diagnoses DO and DO NOT impact the ROM/SOI but are documented in the record
Thank you,
Regina McCroskey, BSN CDS
Cypress Fairbanks Medical Center
Houston, Texas 77065
Regina.McCroskey@tenethealth.com
Phone: 281.897.3146
Comments
We review NICU cases for MD documentation and to ensure that all clinically significant diagnoses are coded.
Some of the important dx's we see at my facility are:
RDS (vs. TTN)-Of note, 'mild RDS' will code to TTN. (RDS generally will have more impact on payment and SOI/ROM. Teaching point: we initially found that there were some errors in coding. The MD was documenting in all notes, "RDS". The clinical picture fit the diagnosis, but at any point, if the MD documented in the resp assessment, "mild resp distress", the coder would instead pick up TTN.. Just something to look out for.
Electrolyte abnormalities-hypo/hyper natremia,kalemia and calcemia can all have an impact-teach MD's to document significance: what did they do about it (monitoring is okay too, but that should be noted to help support dx).
Blood gases-make sure MD's are interpreting the findings when significant-alkalosis and acidosis-also document what they are doing for it.
IVH ; though these are often documented. If you reconcile your cases, just make sure it gets picked up by coding: )
Pneumothorax
Apnea of prematurity-impacts soi/rom
Birthweight-can impact DRG depending on payor. Make sure it is coded accurately.
PFO's and other murmur's -caution-so many nicu babies will have noted pfo's in the cardiology assessment-it would have to be clinically significant to capture in coding; cardiology consult, monitoring, other symptoms, etc..There are coding clinics on this topic that will be a good reference for you.
There are a million diagnoses that can move the soi/rom and drg, but these are just the most common we note deficits in here. The approach of educating the MD's as well as working as a team with Coding has proven to be successful here for accurate capture of soi/rom.
Hope this helps.
Kerry
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
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
Thank you so much for the information. I am sure this is just what I need to get the project going!!!
Regina
Kerry
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
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923