urosepsis

tkreilingtkreiling
in CDI Talk Archive
Does anyone have a query for urosepsis that they are willing to share? Is it too leading to just ask the physician to clarify if the dx he is using of urosepsis is intended to mean UTI or sepsis?
Thanks in advance.

Comments

  • dong.lidong.li
    edited May 2016
    Let me know your email address, and I will email you.
  • dvitalone1dvitalone1
    edited May 2016
    We use this but it is not a permanent part of the record

    Dawn
  • robert.hodges2robert.hodges2
    edited May 2016
    I don't have a query form (my providers know better), but when I do see it how I normally query goes something like this:

    "Urosepsis codes as a urinary tract infection. Are you able to clarify if you intend to document this as a urinary tract infection or as sepsis of a urinary source?"

    I also throw in some words about mortality and morbidity reports and patients in the ICU or dying from UTI's to make my point.

    Hope this helps.

    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
  • robert.hodges2robert.hodges2
    edited May 2016
    Nice form Dawn! Thanks for sharing.

    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
  • NormaBNormaB
    edited May 2016
    We use a query (not a permanent part of the chart) to clarify his/her meaning of the terminology.

    - Simple UTI only
    - Sepsis from a Urinary Tract Infection OR
    - Other Diagnosis

    It has been fairly sucessful in getting the documentation we need.

    NBrunson, RHIA, CCDS
  • dallend@einstein.edudallend@einstein.edu
    edited May 2016
    This is the same verbiage that I use for my query.
  • cynthia.a.goeweycynthia.a.goewey
    edited May 2016
    This is what I use. If the patient does not have bacteremia I just use UTI for b.

    As part of our clinical documentation program I am following X. I see he was admitted with urosepsis. According to coding guidelines urosepsis must be coded as a simple UTI, regardless of S&S, lab findings and treatment. Would you please clarify in your notes if X has a possible/probable sepsis. If one of the following diagnosis is appropriate would you please document in your next progress note:
    a) sepsis due to UTI
    b) UTI with bacteremia
    c) UTI
    d) other

    This clarification will assist us to accurately capture the severity of illness on admission. If you have any questions please do not hesitate to contact me.

    Cindy Goewey RN, BSN
    Clinical Documentation Specialist
    Cindy.Goewey@Hitchcock.org
    Phone: 603-650-3891
    Pager: 4741
    Fax: 603-650-6787
  • tkreilingtkreiling
    Thanks everyone for the great ideas!
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