RE: [MARKETING] [EXTERNAL] querying from nursing documentation
It depends on the circumstances. I always review nursing and other allied health documentation when doing my reviews. That’s how I normally identify malnutrition (dietary consults) and other conditions which providers are not addressing or documenting (incontinence). Often RN’s document these things and providers don’t. The same may be true for disruptive behavior or other conditions which impact nursing care and require increased nursing resources including time, and conditions which impact nursing resources are appropriate to query.
I would not query for a diagnosis if it was me, but I would query for clinical significance, if any, of the nursing observations. It’s up to the provider then to determine if it is clinically significant and if so to document to that effect. Just my two cents here on a Friday afternoon.
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
I would not query for a diagnosis if it was me, but I would query for clinical significance, if any, of the nursing observations. It’s up to the provider then to determine if it is clinically significant and if so to document to that effect. Just my two cents here on a Friday afternoon.
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