do not resuscitate

Unknown

Question re: do not resuscitate

I have a patient who was admitted through ER. ED Physicians documents in his notes 'PT IS A DNR".
This patient arrives to ICU at 0600 and is dead by 0740.

Are we allowed to pick up the DNR off the ED physician note? There are no written orders as no physician saw the patient before death occurred.

Thoughts?


Thanks.

Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Menorah Medical Center

jolene.file

Yes, it is part of the entire inpatient record. You may code anything from the ER chart.

Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com

Unknown

Thanks! Is there something in writing which states this? One of our coding staff feels because there is no order we are unable to capture it.

Charlene

jriley

CMS official coding guidelines permit only documentation by a “healthcare provider” who is defined as “any qualified healthcare practitioner who is legally accountable for establishing the patient's diagnosis.” This would include an ED provider.

This definition of provider may include MD, DO, podiatrists, chiropractors, psychologists, APRNs, PA's CRNA's, and residents and interns who meet the legal requirements. Med students, nurses, nutritionists, physical therapists, respiratory therapists, social workers, and rehabilitation or occupational therapists are not included.

Two exceptions allow documentation of a condition by someone other than the health care provider: BMI and the stage of pressure ulcers. However, the health care provider must still document the presence and location of pressure ulcers, as well as a clinically relevant condition associated with an abnormal BMI.

In addition, for inpatient coding, the health care provider must be “directly involved” in the care of a patient. At a minimum, this requires speaking with and/or touching the patient while providing some sort of care. Therefore, medical reports such as imaging studies, laboratory or pathology reports, EKGs, echocardiograms, and exercise stress testing are not sufficient documentation.

We do not need an "order" to capture the DNR code since a physician has documented the information for us.


Judy

Judy Riley, RHIT, CCS, CPC
Manager Coding/CDI
LRGHealthcare
ext. 3315