patient disposition

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
We have some new (to us) coders working for us now and all the sudden we are frequently being asked to clarify patient disposition as they are unable to find this information or find conflicting information in the record. CDI handles retro queries.
We have never been asked to do this before (which makes me wonder of course how our coders have been able to complete this field) and is not something we generally pay attention to.

Is this something that you look for or query for at your facility. I am trying to determine what is 'normal'.

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

  • lsipos@monument.healthlsipos@monument.health
    edited April 2016
    In our institution we bring that to the attention of the care managers. (assuming by disposition you mean INPT, OBS, EX etc)

    Juli

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Nope, I mean that disposition of where they went after discharge. SNF, Home health, Home, AMA, etc....

    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

  • jolene.filejolene.file
    edited April 2016
    Good Morning, Katy!
     
    The disposition is how the pt. left the hospital .....ie home, SNF, HH, etc.    The way our coders determine this is with the referrals forms, last order on the chart, or the Case Management/Continuing Care notes.  I have coded in several facilities and this is how the information has been obtained.

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

  • lsipos@monument.healthlsipos@monument.health
    edited April 2016
    Again, care managers. But, I would educate your coders (or have their manager do that) on how to find that info in order history etc.



  • lmcnamara@cortlandregional.orglmcnamara@cortlandregional.org
    edited April 2016
    I agree. Discharge disposition should come from Case/Care management and /or discharge planners/SWS….our facility has the unit clerks enter discharge status at time of discharge per Discharge team. (SWS/Case Management,etc). We are also currently trying to have the physician add discharge disposition to the discharge summary, and that helps – sometimes. ;)

    Lona McNamara, RN, BSN, CCM
    Clinical Documentation Integrity Specialist
    Cortland Regional Medical Center
    607-428-5129



  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Right. I agree that this is where it should come from. But does no one else ever have an issue where it is either:

    1. Not in the record

    2. Inconsistent (MD states home with home health but CM states home, patient refused HH)

    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

  • gwojogwojo
    edited April 2016
    Hi Katy,

    I would think the Discharge Planners would have that information and I would direct the new coders to that department.


  • rmhosler1rmhosler1
    edited April 2016
    Katy:I agree w Jolene. This is our practice also. As CDS we don't q for that


    Sent from my Verizon Wireless 4G LTE smartphone

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