querying from nursing documentation

lsipos@monument.healthlsipos@monument.health
in CDI Talk Archive
I am covering charts/queries for a CDI on maternity leave. She has an outstanding query for a patient who presented with GIB who immediatley opted for comfort care, and who subsequently died. (Hypotension, ES COPD, ABLA,recent TKA, etc) (no indicators for sepsis/sirs)......
In any case the CDI queried for a diagnosis related to the NURSES DOCUMENTATION OF INCREASED AGITATION, AMS. Does anyone know of any rules that prohibit query from nursing documentation SOLELY? I personally would not have queried, and assume she did it for the MCC hoping for encephalopathy.

Help! I think this is leading the provider!

Juli

Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    I am not attempting to address the issue here regarding Sepsis as I would like a bit more clinical information..However, I personally DO review the documentation by an RN (clinicians) as I review records. I find that often the RN will precisely document in the legal record physiologic findings that 'could be supportive' of a wide range of potential diagnoses that are not clearly or consistently cited by the MD. If I present these in a query, I take care to restate the precise RN documentation, date, and any apparent interventions/monitoring.

    We are told the 'review the entire record', so I review notes from Pharm, RN, PT, Wound Care, RD...etc.



    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

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Juli
    I responded to your direct email but I will C&P here to add to the discussion :)

    I think it is very common that clear documentation of mental status is often not documented by the MD but is described by nursing. I think is may be appropriate to query for further clarification based on those clinical indicators much like we may query for malnutrition or a decubitus documented by nutrition or wound care. That being said, I would want to ensure that the case was strong. Also, I am always cautious (right or wrong?) in patients on comfort care. There needs to be evidence of monitoring/treatment/etc because often I think conditions arising during the dying process are not monitored or treated. Documentation of any type of restraints, a sitter, frequent monitoring, etc would support the coding of an additional dx if it was documented.

    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


  • cynthia.hudson@christushealth.orgcynthia.hudson@christushealth.org
    edited May 2016
    I agree and do it the same way. This is clinical data just like labs, xrays, etc.

    Syndi Hudson, RN, CCM

    CDI Specialist

    Christus Santa Rosa New Braunfels

    600 North Union

    New Braunfels, Texas 78130

    cynthia.hudson@christushealth.org

    830-643-6116 (Office)

    830-643-5139 (Fax)



  • lsipos@monument.healthlsipos@monument.health
    edited May 2016
    I DO review all these as well, and often use nursing documentation to support a diagnosis. ... I have just never queried using Nursing documentation SOLELY. The provider only ever mentions pt mental status as Alert and oriented. Thanks for the input!

    Juli

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Ugh. Now that is also a problem. Let's say the provider does respond to a query with encephalopathy. This contradicts with their documentation and it may be difficult to support the dx if denied. Now chances are (in my experience), that the MD is documenting A&O out of habit/on a template and the nursing documentation is likely more accurate. In that case, it may be prudent to query for clarification of the discrepancy first and then based on that response query for encephalopathy if indicated.

    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


  • lsipos@monument.healthlsipos@monument.health
    edited May 2016
    He actually states that patient is of sound mind when he makes the decision for comfort care. There was an order for an Ativan gtt per comfort orders. Which was instituted for the patient...

    juli


  • kerryseekircherkerryseekircher
    edited May 2016
    On maternity loa myself and quickly reading from my phone:) just a point to chime in if not already mentioned- if morphine and Ativan are started for comfort care, it might be difficult to support a new diagnosis surrounding ams once these meds have been given.
    Kerry Seekircher
    Sent from my iPhone

    > On Oct 24, 2014, at 12:37 PM, "CDI Talk" wrote:
    >
    > He actually states that patient is of sound mind when he makes the decision for comfort care. There was an order for an Ativan gtt per comfort orders. Which was instituted for the patient...
    >
    > juli
    >
  • lsipos@monument.healthlsipos@monument.health
    edited May 2016
    SO good to get so many insights~ Thanks

    Juli


  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Eeek. If the symptomology described by the nurse began after administration of Ativan or other such meds typically given during comfort care I think encephalopathy would be difficult to support. Drug-induced delirium or acute confusion, maybe. And I would want there to be evidence of some sort of treatment/management.

    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


  • debra.stewart@halifaxregional.comdebra.stewart@halifaxregional.com
    edited May 2016
    YES I use all documentation in the chart to look for appropriate diagnosis that may not have been documented by the provider...but make sure it is appropriate to query for and all criteria meets prior to querying.

    Deb


    Debra Stewart, RN, BSN,
    Clinical Documentation Specialist
    Halifax Regional Health System
    2204 Wilborn Avenue
    South Boston, Va. 24592
    (W) 434-517-3317
    (C) 434-222-9884
    Debra.stewart@halifaxregional.com












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