Making it official

cselukecseluke
in CDI Talk Archive
I've seen several posts about facility definitions for some of the more
ambiguous or hard-to-define medical diagnoses like acute renal failure
or the degrees of malnutrition. For those of you who have developed such
facility definitions, how did you get the official seal of approval? Did
you make the definitions part of a med staff policy or a hospital
policy? How did you handle education of the providers?


Cathy Seluke, RN, BSN, ACM

Team Leader, Clincial Documentation

MaineGeneral Medical Center

149 North Street, Waterville, ME 04901

Phone (207) 872-1796

Pager: (207) 823-0717

Comments

  • sbeattysbeatty
    edited May 2016
    We've just developed several that are going to be presented to Medical
    Staff Quality Management committee this month. This committee includes
    all section chiefs, chief of staff, CMO, medical director of quality,
    and upper level hospital administration. Once approved, we intend to do
    group practice education. Our content has been developed from the
    professional associations and colleges of most of our sub-specialty
    groups, and from the physicians' own professional literature. We intend
    to have a standard format for queries, and insert the diagnosis-specific
    data and our query statement into the base form. I will let the group
    know how this goes. Developed so far:

    Sepsis/severe sepsis/SIRS/septic shock, malnutrition, CKD, ARF, acute
    respiratory failure, chronic failure, NSTEMI, STEMI, heart failure-there
    may be others that I'm forgetting. I'll keep the group posted.

    Sandy Beatty, RN, BSN, C-CDI

    Clinical Documentation Specialist

    Columbus Regional Hospital

    Columbus, IN

    (812) 376-5652

    sbeatty@crh.org

    "The difference between the right word and the almost right word is the
    difference between lightning and the lightning bug." Samuel "Mark Twain"
    Clemens


  • cstukenbergcstukenberg
    edited May 2016
    Would you be willing to share?


  • fostermafosterma
    edited May 2016
    I would be interested in seeing your definitions. Sounds like a great approach. Roberta


  • dsmith12h@aol.comdsmith12h@aol.com
    edited May 2016
    We have been working toward this goal at our Hospital but haven't gotten much support. Most all staff member that have been approached relative to gathering data all agree that they are happy to help but they haven't followed through.

    I would love to see what you have developed if you wouldn't mind sharing the data.

    dsmith12h@aol.com






  • Unknown
    edited May 2016
    I do a monthly physician newsletter and include 1-2 definitions every
    month. This month I did the entire thing on sepsis and all the
    different types of sepsis and what coders need documented. I work at a
    teaching hospital and give the newsletters to every case manager to hand
    out and I post them at documentation areas throughout the hospital, in
    the medical records department, and in the resident call rooms. I also
    do resident training sessions 4-5 times/month and talk about things
    there.

    Stacey Forgensi, RN, CCRN, CCDS
    Clinical Documentation Specialist
    Erie County Medical Center
    sforgens@ecmc.edu
    Pager 642-1011



  • robert.hodges2robert.hodges2
    edited May 2016
    I do something similar. My copy going out tomorrow discusses the RIFLE
    criteria for acute renal failure. Chronic kidney disease staging and
    Anemia have been in past issues. It's always good to have national
    standards to back up what you're trying to teach.



    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



    "To climb a steep hill requires a slow pace at first." -William
    Shakespeare




  • cstukenbergcstukenberg
    edited May 2016
    I also do a newsletter which I just started in November.



  • sbeattysbeatty
    edited May 2016
    Roberta,

    You asked me for something else once before and I don't have your
    individual email. Please contact me off line if you recall what it was
    and I'll see if I can help. I've lost the email now.



    Sandy Beatty, RN, BSN, C-CDI

    Clinical Documentation Specialist

    Columbus Regional Hospital

    Columbus, IN

    (812) 376-5652

    sbeatty@crh.org

    "The difference between the right word and the almost right word is the
    difference between lightning and the lightning bug." Samuel "Mark Twain"
    Clemens


  • cstukenbergcstukenberg
    edited May 2016
    Sandy

    Would you send them to my email also?

    Cstukenberg@fhn.org.

    Thanks,

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

  • michelle_thimmeschmichelle_thimmesch
    edited May 2016
    Sandy,
    I would also really appreciate a copy.
    Michelle_Thimmesch@via-christi.org

    Thanks so much,

    Michelle Thimmesch, RN, MSN
    Manager, Compliant Documentation
    Via Christi Regional Medical Center
    Wichita, KS
    316-268-8570


  • johnsok5johnsok5
    edited May 2016
    Hi Sandy could I please have a copy also? This sounds interesting.

    johnsok5@ccf.org

    Thanks for sharing this.


    Sincerely,

    Karen A. Johnson




  • massimo.gentilemassimo.gentile
    edited May 2016
    Sandy

    I would also like a copy. massimo.gentile@hma.com

    Thank you for sharing.




  • cbarnescbarnes
    edited May 2016
    Sandy, I would also like a copy. Thanks for the information and the willingness to share. Charlene cbarnes@hmh.net


  • tdavistdavis
    I know if you send it to bmurphy@cdiassociation.com it is usually very timely at getting info posted to the forms/tools sec. Melissa is also very helpful. You can click on the link under the forms & tools library and send the info to them that way as well.

    By the way - great question Cathy!
  • Unknown
    edited May 2016
    Do you share this information?

    Kim Beard
    Clinical Documentation Specialist




  • sbeattysbeatty
    edited May 2016
    I sent all of them to the list yesterday, but apparently it was too
    many/too large for the list to handle. I'm in the process of sending
    them to Brian & Melissa to post in Forms & Tools. Remember, these are a
    work in progress. I have no approval yet (besides the CMO and Medical
    Director of Quality) until the section chiefs critique and approve at
    the Medical Staff Quality Management meeting which is Jan 25th. My
    deadline to get these on the agenda is 1/18, so I'm under the gun. In
    the meantime, my manager expects me to perform my daily duties ,
    so I need to get out to the units. I'll defer to Melissa or Brian to
    post to the list when these are uploaded.



    Thanks to all for the support-I think this is important work, and I love
    thinking of new and different ways to accomplish our goals, all while
    supporting the big picture (SI/IS, RAC, quality indicators, etc.)



    Sandy Beatty, RN, BSN, C-CDI

    Clinical Documentation Specialist

    Columbus Regional Hospital

    Columbus, IN

    (812) 376-5652

    sbeatty@crh.org

    "The difference between the right word and the almost right word is the
    difference between lightning and the lightning bug." Samuel "Mark Twain"
    Clemens


  • Unknown
    edited May 2016
    I am getting into the conversation at the tail end, but if you have shared and are willing to share, I would be interested.  Thank you.
    Adrienne

    Adrienne Gmeiner RN, CCS
    Clinical Documentation Improvement
    Lawrence General Hospital
    Telephone # 978.683.4000  X 2261
    email: adrienne.b.gmeiner@lawrencegeneral.org


  • Unknown
    edited May 2016
    Hi Sandy, That sounds great If you can share that would be extremely
    helpful.

    cheyn@elliot-hs.org






  • sbeattysbeatty
    edited May 2016
    WOW! I had no idea the response would be so large. Yes, I'm willing to
    share. I just finished sending the ones I have in some semblance of
    completion to Melissa and Brian for posting to the Forms and Tools
    section of our website. Please remember that these are a work in
    progress. For instance, Tamponade needs fleshed out.....Once this MSQM
    meeting is over, I'll let you know what happened with the approval
    process. Thanks for all you do to support CDIP!!



    Sandy Beatty, RN, BSN, C-CDI

    Clinical Documentation Specialist

    Columbus Regional Hospital

    Columbus, IN

    (812) 376-5652

    sbeatty@crh.org

    "The difference between the right word and the almost right word is the
    difference between lightning and the lightning bug." Samuel "Mark Twain"
    Clemens


  • michele.goossenmichele.goossen
    edited May 2016
    Sandy,

    I would also like a copy if you are wiling to share. My e-mail address is: Michele.Goosen@LRMC.com

    Michele Goossen, RN, BSN, CHCQM
    Clinical Documentation Specialist
    Lakeland Regional Medical Center
    863-687-1369



  • sbeattysbeatty
    edited May 2016
    Great news!! I just heard from Brian who has the ones I've drafted and
    plan to take this month, a few with some additional revisions. I have no
    problem sharing so others can see what is possible. However, I would
    like to publish something about this project, once I know something
    about the approval process results, and what impact these queries
    actually have/don't have. I'm still thinking that through. So I would
    only ask that you remember that this is the work of the Columbus
    Regional Hospital CDIP and give credit where credit is due. Having said
    that, please provide me with any and all feedback about format, content,
    definitions, etc. If you have a different resource for diagnostic
    criteria I would love to know. I teamed with our cardiovascular data
    collection nurse on the cardiac criteria. It seems the software we use
    to report cath lab data had an entire section of operational
    definitions. I borrowed heavily from that information. Those were my
    most recent ones and they still need work. ENJOY!



    Vascular disease is in the works, and I'm trying to decide if I can get
    cerebrovascular, PAD, and PVD all in one table without totally confusing
    the MDs.



    Sandy Beatty, RN, BSN, C-CDI

    Clinical Documentation Specialist

    Columbus Regional Hospital

    Columbus, IN

    (812) 376-5652

    sbeatty@crh.org

    "The difference between the right word and the almost right word is the
    difference between lightning and the lightning bug." Samuel "Mark Twain"
    Clemens


  • Unknown
    edited May 2016
    I would be very interested in these definitions also. Our physicians are
    always asking us for criteria. I agree you need something to back up
    what you are trying to teach. If you don't mind sharing-----Thanks.



    gspatafore@wtbyhosp.org





    Gina Spatafore, RN

    Clinical Documentation Integrity Specialist

    Waterbury Hospital

    203 573 7647




  • Unknown
    edited May 2016
    Sandy:

    Would you please share a copy with us here?

    Thanks
    Ellen
    ellen.chang@stalexius.net




  • bmurphy@hcpro.combmurphy@hcpro.com
    edited May 2016
    Thanks again Sandy.

    FYI, everyone, these are now all posted in the forms and tools library, so no need to e-mail Sandy directly.

    Also, as Sandy has noted these are examples, and will need review and approval by individual medical staffs.

    Take care,
    Brian


  • bonnie.diehrbonnie.diehr
    edited May 2016
    Does anyone have a presentation I could borrow for our Pediatric Section? Our hospital is receiving denials from certain insurance carriers related to the changes in the Newborn Coding Guidelines; which state that the discharging physician must document any and all conditions treated, montiored, etc. Our physicians use a admitting/discharging exam sheet for recording diagnoses and the insurance companies want a discharge summary.

    I need to be convey to our medical staff the importance of documenting everything treated in a summary note whether handwritten or dictated.

    Thanks
    Bonnie
    Bonnie.Diehr@mjh.org



  • jolene.filejolene.file
    Hi Bonnie!

    I am not aware of any new newborn coding guideline.
Sign In or Register to comment.