Use of Nursing Notes for Clinical Validation

proddy@clarionhospital.org

I know coding cannot code from nursing documentation but I wonder if you are using nursing notes to clinically validate a diagnosis? I have a case where one of the dx is Acute Respiratory Failure. The pox is 79% room air initially and 95% on 4L O2, no use of home O2 prior to this.  The ER physician record as well as the H/P state no signs of respiratory distress or tachypnea, although progressively increasing SOB/DOE noted.  Then I noticed the ER doctors first review of systems/ resp assessment finding is timed for 3 hours after her arrival.  When I checked nursing notes, it states, respiratory distress, tachypnea, etc.  In light of audit risk/vulnerability, would you consider this nursing note info in the ER to determine whether you need a clinical validation query?

evanspx@sutterhealth.org

I use the entire record as part of any/all reviews, to include ‘Clinical validation’.   The RN notes are often very helpful in terms of noting issues, such as GCS scores, emaciation, abrupt changes in mental status, positive sepsis alerts,  and much more.  I think the query should specifically reference these are nursing notes and also provide the date/time the notes were written, along with an impartial citation of the pertinent clinical information.   My opinion is that one should use the entire record judiciously in our efforts.
Paul Evans, RHIA, CCDS

proddy@clarionhospital.org

Thanks Paul,
I may have worded that differently than what my thoughts were.  Would you use nursing notes to help you decide whether you needed to query?  In this scenario,  just based on physician documentation I have notes that say no resp distress or tachypnea, a low pulse ox and O2 at 4L, so no apparent validation beyond that.  But that appears to be the untimeliness of the ER doctor as her presenting symptoms of labored breathing, tachypnea, etc are found in nursing record are not mentioned in the physician notes

evanspx@sutterhealth.org

Yes: I often use nursing notes as a supplement to help me decide if/when/how to analyze a case, and if applicable, will cite the RN notes as context in the query.   Sometimes, due to cut, copy and paste or simply due to timing, I have observed clinical observations in the RN notes that are not the ‘same’ as the MD.    Given the RN is recording clinical observations,  I think it would be valid to address the RN notes.  Hope this helps?

proddy@clarionhospital.org

thanks Paul!!