RE: [EXTERNAL] RE: Diagnosis without clinical indicators
I disagree. You can query to request information supporting the diagnosis the provider has made if there are no clear clinical indicators present. It's all part of getting the provider to put their thought process in the record and how they came to that diagnosis.
Just my opinion here, but yes I would query.
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
Recently we have seen an increase in the documentation of sepsis with little to no clinical indicators. I have a query that ask for supporting clinical indicators but what do you do when there are NO clinical indicators to support the diagnosis?
Thanks,
Dorie Douthit
ddouthit@stmaryshealthcare.org
Just my opinion here, but yes I would query.
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
Recently we have seen an increase in the documentation of sepsis with little to no clinical indicators. I have a query that ask for supporting clinical indicators but what do you do when there are NO clinical indicators to support the diagnosis?
Thanks,
Dorie Douthit
ddouthit@stmaryshealthcare.org