Querying for lab results after discharge

tkreiling

I was curious on the opinions of others if it is appropriate to query a physician for a positive C-diff result that came back after the pt was discharged? The reason I am uncertain of whether or not to ask for the dx is that the pt was not given any treatment for the C-diff so not sure it is okay to query/code? If anyone has thoughts on this can you please share.
Thank you.

kshumpert

I would only query if it was a condition that was treated or if it further clarified a condition that was treated or monitored. Was the c diff screen ordered for diarrhea?


Kathy
Kathy Shumpert, RN, BSN

Clinical Documentation Improvement Specialist
Howard Regional Health System
Office 765-864-8754
Pager 765-604-0424
Fax 765-453-8152

There are thousands of thoughts lying within a man that he does not know till he takes up the pen and writes. ~William Makepeace Thackeray

digardsk

Sometimes we make sure the physician is aware of lab results (often UAs) regardless of whether we are querying for our CDS purposes. In the interest of patient care...

cstukenberg

I agree, I try to focus on quality of care and not just the documentation. Some test results do not come back until after d/c (i.e. cultures or path reports).

hmhmay

Depending on the significance of the result. Sometimes even if a case had not been treated and I feel that it is clinically significant, I will pursue the result with the physiciam to ensure appropriate follow up. Perhaps it is a condition that does require treatmenet or follow up in the outpatient setting. I want to alert the physician so that care for a patient does not fall through the cracks regardless of whether I obtain documentation or not.

catladyrn

I would not query it. If the doc didn't know about it during the stay, how did it impact the stay? Plus we are not allowed to do retrospective queries.

As for notifying the physician, shouldn't the lab have done that? Or does the result go into their round file after discharge? Seems like a public health issue to send home a pt w/C.diff and not make them aware. Someone within the hospital--infection control, maybe, if not the lab--needs to have ownership of that issue.

Renee


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

Unknown

Now this is a clinical documentation improvement specialists that sees the value and role of clinical documentation specialists beyond the capture of the all mighty CC/MCC and the number of queries left and whether its impact case mix. Good to see CDIS that are proactive.

dallend@einstein.edu

I agree - I would not query since it was not treated. At our facility the lab notifies our physicians of abnormal lab results/culture results if they come in after discharge.
We do retrospective queries for clarification for patients we do not see or for patients who may have had a condition develop after our last review.

cstukenberg

I do agree that the lab should be involved in the process of notifying providers of abnormal labs after discharge. However, since we do retro queries, I would not have a problem of notifying the dr and/or putting it on the query form.

Colleen Stukenberg MSN, RN, CMSRN, CCDS
815-599-6820

NormaB

We have queried physicians retrospectively (actually the coders do this) for path results which are positive for cancer results and have somewhat good results from these queries.

impretty sure our Infection Control dept is notified of all abnormal lab that would impact the coomunity as well as our LAB notifies the physician of results.

I think this would warrant a query.

N.Brunson, RHIA, CCDS