RE: [EXTERNAL] RE: end stage CHF
Why not query? Even without an EF the provider could give a possible or probable type based on the clinical presentation of the patient? Does the CXR show evidence of cardiomegaly (possible systolic) or congestion of the pulmonary veins, pleural effusion, or pulmonary edema (left failure)? Is there hypertension associated with the heart failure (possible diastolic) or peripheral edema (right failure)?
I still feel it's worth asking the question just to capture the SOI and who knows, you may even get an answer.
Robert
Robert S. Hodges MSN, BSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VA Medical Center
1500 Weiss Street, ATTN PAS-136
Saginaw MI 48602
989-497-2500 x13101
Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
I still feel it's worth asking the question just to capture the SOI and who knows, you may even get an answer.
Robert
Robert S. Hodges MSN, BSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VA Medical Center
1500 Weiss Street, ATTN PAS-136
Saginaw MI 48602
989-497-2500 x13101
Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens