Must every diagnosis be ruled in or out.
Frequently the night shift hospitalist will admit pts during the night and list several diagnoses on the H&P. The dayshift hospitalist then rounds on the pt daily and completes subseqent progress notes. Often times, the dayshift hospitalist does not repeat some of the diagnoses in the progress notes. The coders believe that each diagnoses must either be repeated or ruled out.
For example, H&P: Sepsis secondary to hospital acquired pneumonia, meeting 2 out of 4 SIRS criteria, tachycardia and tachypnea as well as likely diastolic congestive heart failure exacerbation. Acute hypoxic respiratory failure, likely multifactorial. COPD exacerbation.
1 PN: COPD exac, possible bronchiectasis exacerbation. CAP. Acute hypoxic resp failure.
The CDS did clarify regarding the CHF as the pt was receiving Lasix 20 mg IV BID.
2 PN: COPD exac, possible bronchiectasis exacerbation. CAP. Acute diastolic heart failure. Acute hypoxic respiratory failure.
DC Summary: COPD exac, possible bronchiectasis exacerbation. CAP. Acute diastolic heart failure. Acute hypoxic respiratory failure.
The coder insists that the Sepsis needs to documented or ruled out on the dc summary. Alot of our physicians do not like to rule out another physician's diagnoses and will leave a diagnosis off of progress notes and dc summary rather than ruling out a diagnosis.
Should the dayshift hospitalist rule in or rule out every diagnosis (including possible diagnoses) documented in the H&P?
Any advice will be greatly appreciated.
Sara
For example, H&P: Sepsis secondary to hospital acquired pneumonia, meeting 2 out of 4 SIRS criteria, tachycardia and tachypnea as well as likely diastolic congestive heart failure exacerbation. Acute hypoxic respiratory failure, likely multifactorial. COPD exacerbation.
1 PN: COPD exac, possible bronchiectasis exacerbation. CAP. Acute hypoxic resp failure.
The CDS did clarify regarding the CHF as the pt was receiving Lasix 20 mg IV BID.
2 PN: COPD exac, possible bronchiectasis exacerbation. CAP. Acute diastolic heart failure. Acute hypoxic respiratory failure.
DC Summary: COPD exac, possible bronchiectasis exacerbation. CAP. Acute diastolic heart failure. Acute hypoxic respiratory failure.
The coder insists that the Sepsis needs to documented or ruled out on the dc summary. Alot of our physicians do not like to rule out another physician's diagnoses and will leave a diagnosis off of progress notes and dc summary rather than ruling out a diagnosis.
Should the dayshift hospitalist rule in or rule out every diagnosis (including possible diagnoses) documented in the H&P?
Any advice will be greatly appreciated.
Sara
Comments
Confirm or Rule Out
Please confirm or rule out the stated condition.
Query:
The diagnosis of (diagnosis) was documented on (Date) in (Note Type) section, but is not consistently noted in subsequent documentation. Monitoring, evaluation and treatment includes:
Please confirm or rule out the stated condition.
The purpose of this query is to ensure accurate coding, severity of illness and risk of mortality compilation. When responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
Provider Query Response*:
0 The (diagnosis) was present and is now resolved
0 The (diagnosis) is present
0 The (diagnosis) was ruled out
0 The (diagnosis) is likely, suspected or probable
0 Unable to determine
0 Other (please specify)*
If diagnosis is still likely, suspected or probable at the time of discharge, please document as such in the discharge summary.
You may answer this Query by marking the checkbox(es) above or using free text at the ( * ) if appropriate.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404