Documentation in the Orders

vleadbetter@cmcvtx.org

Question:

One of our Orthopedic Surgeons uses pre-printed orders for his surgeries. One of the post-op orders reads, "If Hemoglobin * 8 g/dL, transfuse 2 packed cells for acute postop blood loss anemia." He will not document the anemia in his progress note. The coding department feels too much is left up to interpretation, ie if the patient only gets one unit, etc. They do not feel comfortable coding the anemia for cases where the documentation is only in the orders.

Any thoughts? If the doctor refuses to document in the progress notes, we will be missing some opportunities to show the severity of illness of these patients.

Thanks,
Vickie Leadbetter

cmorell

Explain to the doctor that each progress note must stand on it's own for medical necessity and that when the insurance company or RAC reviews the chart for medical necessity if it is not documented in the body of the medical record they will deny the diagnosis. Explain that the goal is to have a complete accurate medical record that withstands scrutiny.

johnsok5

This sounds like a standing order to me, we would need stronger
documentation to support it also.

robert.hodges2

Perhaps this is an educational opportunity to let them know this could reduce their number of post-op complications if it is an expected blood loss anemia. Just a thought.



Robert



Robert S. Hodges, BSN, MSN, RN

Clinical Documentation Improvement Specialist

Aleda E. Lutz VAMC

Mail Code 136

1500 Weiss Street

Saginaw MI 48602



P: 989-497-2500 x13101

F: 989-321-4912

E: Robert.Hodges2@va.gov



"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens

catladyrn

I am curious why he is willing to document it in his orders but not in his progress notes. There are diagnoses I would take from orders but not one that is associated with a PRN order, any more than I would think "Tylenol prn h/a" means the coder should code headache.

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center