Diagnosis in ED not documented during Admission
We recently had a case where the ED provider stated "Sepsis and Pneumonia" on the ED note. However, when the Admitting provider wrote the H&P he stated UTI d/t Foley with no mention of Pneumonia or Sepsis. Throughout the documentation, during the patient's visit, the only mention of Sepsis and Pneumonia was in ED without clinical indicators. I spoke with the Admitting provider who will not add R/O for the diagnoses. The ED provider is adamant that those were the diagnoses while the patient was in ED.
Can someone help me....is anyone having this issue? Should the ED provider change their documentation or should the Admitting provider add ruled out?
Any information would be greatly appreciated!
Comments
-ER record includes admission diagnosis of NSTEMI
-EKG in ER: Rate is 109/min. Rhythm is irregularly irregular. QRS Axis is normal. PR interval is normal. QRS interval is normal. QT interval is normal. Clinical impression: A-Fib.
-Troponins 0.062, 0.058, 0.043, 0.049
-Treatment includes ICU, cyclic iso/troponins, heparin drip.
based on your medical judgment, and above indicators, do you concur and wish to include the diagnosis NSTEMI
-Yes include NSTEMI
-No, NSTEMI has been ruled out
-Other (specify)
If there is documentation supporting the ED record diagnoses, we would query the attending if they agreed with the diagnosis.
I would also never asked an ED physician to change their diagnosis, you mentioned that the pneumonia and Sepsis were without clinical indicators, what clinical evidence was present for the UTI?
Agree w/ logic cited per others: Would query the Attending for confirmation if clinical indicators are supportive. Many conditions are noted as potential at the time of admission, later ruled out, and as such, are not coded.
P. Evans, RHIA, CCDS
Agree w/ Sharm. I'd never ask the ED physician to alter a diagnosis. The role of ED is to stabilize and triage - they can't/won't wait too long in order to record a 'working diagnosis', but may record a variety of symptoms and/or potential (working) diagnosis as they make determination as to disposition of the patient. As such, it is very common for an ED MD to record a working diagnosis such as MI, PNA, Sepsis, with any particular condition being later modified at a later date when more time has been provided for definitive diagnosis.
Paul Evans
CCDS