Suspected Renal Pathology diagnosis for AKI

blefevre

Does anyone have a query template sheet for asking the physicians to be more specific about the suspected renal pathology for a Dx of AKI? For example, The suspected cause of AKI might be Acute Tubular Necrosis (ATN) which is an MCC and would better reflect the severity of illness and mortality risk. If so, would you be willing to share with the group?

Thank you,
Barbara Lefevre RN BSN CCDS
Saint Mary's Hospital
Waterbury, Connecticut

mary.a.dunn

I do have a template for a query and am happy to share. I will try to attach it to this email; If it doesn't work you can email me
Mary.a.dunn@comhs.org



Mary Dunn RN BSN MSM
Clinical Documentation Specialist
Community Hospital
Munster, Indiana 46321
ext 5612
phone; 219 513 2612
pager 219 222 2217

deanna.schad

Barbara,

This is the query template that we are currently using in an attempt to get greater specificity on these renal diagnoses. We involved our renal docs for imput to ensure we were on track with the criteria.

Let me know if you have any questions.

Dee Schad, RN, BSN, CCDS
Manager, CDI
Jewish Hospital & St. Mary’s HealthCare
Louisville, KY

dbutler

Notice that the template includes:
"The medical record reflects the following clinical findings and laboratory values:
GFR______ BUN______ CREATININ_______"

Do you usually add clinical indicators? or only complete the phrase?
Would think that you would want to include additional information (established baselines, trend of values, comorbid conditions that may be affecting renal function, etc.), quotes from the record, etc.

Don

mary.a.dunn

We usually just fill in the top blanks for GFR, Bun, CRt. We found that for the most part the doctors especially renal are familiar with the documentation in the chart. They just tend to fall back to the " older form " of documentation when they are in a hurry. We have one nephrologist who always documents his dialysis patients as chr renal insuff. He gets a query every time.
Mary