Querying OB Doctors for ABLA

smilingso@aol.com

I've read many articles regarding physicians documentation of  ABLA following a woman's delivery. It's a bit confusing as there are differing opinions.  Does anyone have  specific guidelines I can use to present to our OB group? 

I've also read that the documentation of ABLA in our OB patients would improve our CMI. Any comments on this?

matthewayinde@hirecdi.com

Hi Smilingso,

ABLA is both a severity driver and also a CC that if clinical evidence exists and properly documented it should be captured.  

Notice I mentioned "if clinical evidence exists":

The clinical evidence I personally look for:

1. The source of blood loss is established (Mechanism of blood loss noted? trauma v Surgery v Other conditions). In your case that will be due to "delivery"

2. H&H drops significantly from baseline that warrants serial monitoring of H&H, and /or treatment w/PRBC or volume replenishing. 

3. Symptomology:  Hypotension and tachycardia 

Notice I also mentioned "properly documented":

1. Acuity and Physiology of the condition: "due to acute bleed" or "due to acute blood loss"

2. The condition: Anemia 

3. Be alert of documentation such as "post-op anemia" or "Blood loss due to surgery". This will require clarification with the provider as to the intended use of "post-op" to mean a complication of the surgery or expected blood loss. We rely on the physician's judgment to clarify the term.

smilingso@aol.com

matthewayinde@hirecdi.com said:

Hi Smilingso,

ABLA is both a severity driver and also a CC that if clinical evidence exists and properly documented it should be captured.  

Notice I mentioned "if clinical evidence exists":

The clinical evidence I personally look for:

1. The source of blood loss is established (Mechanism of blood loss noted? trauma v Surgery v Other conditions). In your case that will be due to "delivery"

2. H&H drops significantly from baseline that warrants serial monitoring of H&H, and /or treatment w/PRBC or volume replenishing. 

3. Symptomology:  Hypotension and tachycardia 

Notice I also mentioned "properly documented":

1. Acuity and Physiology of the condition: "due to acute bleed" or "due to acute blood loss"

2. The condition: Anemia 

3. Be alert of documentation such as "post-op anemia" or "Blood loss due to surgery". This will require clarification with the provider as to the intended use of "post-op" to mean a complication of the surgery or expected blood loss. We rely on the physician's judgment to clarify the term.

Thank you, Matthew!