FW: [EXTERNAL] RE: end stage CHF
I agree with Robert. I try not to assume that the MD's won't have an answer and just ask the question. I don't think there is anything leading or presumptive about that simply because the EF is missing-especially if you can support the query with other clinical indicators and pmh. Many times too, while they don't document it, there may have been a verbal conversation with a cardiologist in planning care for the patient. I've had 'unknown ef' copied/pasted throughout the chart, and when you ask, the MD has since found out that information but just not updated the record-ie; conversations with other specialists/access to outpt records.
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
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