Clinical Validation

Melissa.addis@kdmc.kdhs.usMelissa.addis@kdmc.kdhs.us
in Clinical & Coding

Does anyone have a clinical validation query that they are willing to share? If one has already been shared, can someone point me in that direction?


Thanks in advance!

Melissa

Melissa.horn@kdmc.kdhs.us

Comments

  • tpeyton1tpeyton1

    we present our findings that may (or may not) support a documented diagnosis, and ask for additional objective information to support that diagnosis -  the response  options in 3M are:

       »  Condition exists and additional clinical indicators documented in the medical record (please document in your next progress note)
       »  Condition does not exist and amended documentation provided in the medical record (please provide amended documentation in your next progress note)
       »  Unable to provide additional clarity regarding the diagnosis
       »  Other (please specify)___________________________
       »  Unknown

    This way, the physician is not put on the defense by us questioning his/her diagnosis.

  • Melissa.addis@kdmc.kdhs.usMelissa.addis@kdmc.kdhs.us
    tpeyton1 said:

    we present our findings that may (or may not) support a documented diagnosis, and ask for additional objective information to support that diagnosis -  the response  options in 3M are:

       »  Condition exists and additional clinical indicators documented in the medical record (please document in your next progress note)
       »  Condition does not exist and amended documentation provided in the medical record (please provide amended documentation in your next progress note)
       »  Unable to provide additional clarity regarding the diagnosis
       »  Other (please specify)___________________________
       »  Unknown

    This way, the physician is not put on the defense by us questioning his/her diagnosis.


    Thank you! :)
  • cericson1cericson1
    You may want to reference the AHIMA Practice Brief: Clinical Validation: The Next Level of CDI - here is a sample of their query

    The following is an example of documentation associated with the diagnosis of sepsis. The clinical scenario is as follows:

    78-year-old female presents with a change in mental status, fever/chills, painful urination and feeling weak all over. Physician exam reveals tachycardia with a temperature of 102 degrees, with all other systems within normal limits. Admit diagnosis: Sepsis due to UTI. Day 1 Progress note: Patient less confused; frequent & painful urination; started on oral antibiotics. Day 2 Progress note: WBC within normal limits; temperature 99 degrees, continue with course of antibiotics and discharge. Discharge Diagnosis: Sepsis.

    The question that needs to be asked is "Do the clinical indicators overwhelmingly support the diagnosis of sepsis, which is frequently challenged for a lack of clinical significance?" It could be argued that sepsis is not supported by the totality of the record due to lack of IV antibiotics, lack of an infectious disease consult, lack of sustained abnormal clinical values and short length of stay. Consequently, the physician should be queried to validate the diagnosis of sepsis.

    Sample Query

    Sepsis was documented as a discharge diagnosis in this patient with the following clinical scenario (see above). Based on standard recognized clinical criteria for sepsis… [Note: include documentation here of facility criteria or other standard criteria for sepsis]. Can you please clarify the status of sepsis, as follows:

    ◻Ž        Sepsis was confirmed
    ◻Ž        Sepsis was ruled out
    ◻Ž        Sepsis was without clinical significance
    ◻Ž        Unable to determine
    ◻Ž        Other ______________

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org

    I like the language used here:  "Based on standard recognized clinical criteria for sepsis {Note: include documentation here of facility criteria or other standard criteria for sepsis}

    P. Evans, RHIA, CCDS

  • hooter1964hooter1964
    additional language:

    Regarding the___________,and based on clinical circumstances, findings, and sound professional judgment informed by evidence-based medicine, please clarify the status of the condition:

     ___ was present on admission and is now resolved

    ___ was present on admission and is still being monitored, evaluated, or treated

    ___ was ruled out

    ___ still a likely, suspected, probable diagnosis

    ___ Other

    ___ Unable to determine 

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