end stage CHF

tkreilingtkreiling
in CDI Talk Archive
I was wondering others thoughts on this situation: Patient is admitted with pneumonia, has end stage CHF (on hospice) and history and physical mentions that the son does not know the EF. No echo is done as inpatient, no records requested from other facility that would have the echo on it. Patient is still taking his Lasix in the inpatient setting.
Would a query for CHF type be needed? My thinking was not to do a query concurrently as the physician states the EF is not known, so really not sure how the physician could give us a type. I have been asked to query post dicharge.
Thoughts? Is a query needed?
Thank you,
Tara RN, CCDS

Comments

  • Unknown
    edited May 2016
    I'm with you - what would you use as the physician has stated unknown EF?


    Charlene


  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    I would not query as the MD can't respond as to the type of CHF.

    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.412.9421

  • carlena.forshacarlena.forsha
    edited May 2016
    There are other ways a physician can determine the most likely type of CHF. As you stated, the patient takes Lasix. What other meds are they on that could indicate the type? What risk factors or comorbid conditions do they have? What does the assessment reveal ie., BLE edema, JVD, SOB, murmurs? Do the labs/radiology reports reveal anything, what is the BNP? Your physicians will likely have a strong suspicion regarding the type of CHF despite an EF not being documented.

    Is there a way to have a face to face conversation with the physician?

    --Carlena MSHCA, BSN, RN, CCDS

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