infection prevention

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
I am wondering if you can share how your infection prevention team documents when they identify a hospital associated infection (CAUTI, VAP, C-diff, SSI, etc). Our IP team currently does not document in the medical record at all, only in their own tracking software and I am wondering if that is the norm or if other facilities handle this differently.

Thanks!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

Comments

  • kshumpertkshumpert
    edited May 2016
    We have the same process as you do.

    Thanks,
    Kathy
    [cid:image001.jpg@01CFEF7B.0B864B00]
    [cid:image002.jpg@01CFEF7B.0B864B00]

    Kathy Shumpert, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Community Howard Regional Health
    3500 S Lafountain
    PO Box 9011
    Kokomo, IN 46902
    O 765.864.8754 | C 765.431.0123 | F 765.453.8447 | E kshumper@communityhoward.org




  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    This is what I was expecting. So is there a process in place to notify CDI when a dx has been made? We have NOT been encouraged to query for these conditions because IP feels like they are the appropriate people to be making this determination and there are concerns that the MD's would designate infections as HACs when they are not (like anytime a patient is identified as having a UTI after foley insertion). However, we are not privy to these dx when made by IP.
    Our HAC data for infections as coded versus as perforated are completely different and the hospital would like to see this come into alignment as much as possible.

    And for the record, I just HATE this legal business that discourages transparency in the medical record.....

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Yes, helpful ☺. I have discussed similar systems with other CDI’s and I am hoping to implement a similar process here.

    A process such as yours will help prevent over-identification but it does not solve the issue of under-identification/documentation. What about those cases identified by IP but NOT documented in the record? We actually have a lower CAUTI/VAP rate being reported by coding than what is identified by IP….

    Thanks!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I agree. And I do not think the doctors are opposed to documenting it. They just need to tools to do so accurately.

    Thanks for your help ☺

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited May 2016
    If I recall correctly, Tamara from Winston-Salem Baptist did a nice
    presentation that included their process along these lines last year
    (maybe the year before) at the ACDIS conference.

    Yep, here it is:
    2013 Conference, Track 3: Partnering With Quality Assurance: The Impact
    of CDI on Quality Reporting

    Don

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