Using Clinical Indicators from Previous Admissions??

SkylerLee83SkylerLee83
in Clinical & Coding

Hello! Does anyone use data from previous admissions as clinical indicators on queries?

For example, we can look to see if an ECHO has been done within the past 6 months and use the EF if there isn't one on the record to query for Type of CHF.

Anyone else do anything similar to this? Use renal labs to establish a CKD baseline? Use pre-op labs for renal status/anemia?


Comments

  • bbogda@morrishospital.orgbbogda@morrishospital.org

    Yes, I do.  I think it referencing that data helps to support why you are asking the question.  In addition to your examples, I will look back at recent visits to compare weights to see if there has been a weight loss associated with poor appetite, dysphagia, etc to help establish diagnosis of malnutrition.

  • lprescott1lprescott1
    SkylerLee83 do review the ACDIS/AHIMA Guidelines for Compliant Query update. It speaks to using clinical indicators from previous encounters. you can find it in our resource library.






  • SkylerLee83SkylerLee83
    lprescott1 said:
    SkylerLee83 do review the ACDIS/AHIMA Guidelines for Compliant Query update. It speaks to using clinical indicators from previous encounters. you can find it in our resource library.







    This is actually what sparked my question! It made me curious as to what other hospitals were doing or if anyone was doing this now? Should we start adapting this practice or expanding what we currently do?As I mentioned before we go back 6 months to look for an EF is there is no documentation of one in the current record. What are other hospitals doing? Looking back at renal labs - if so, how far back do you look?

    As mentioned above, BMI is a good example of something from a previous admission that could help establish a diagnosis of malnutrition.

    Is there anything else that I am not thinking of?

  • Jane.Brown@ensemblehp.comJane.Brown@ensemblehp.com
    CKD staging.  We welcomed the new brief!!
  • SkylerLee83SkylerLee83
    jbrown5@ecommunity.com said:
    CKD staging.  We welcomed the new brief!!
    jbrown - do you have any specific guidelines to follow for this? Only use labs within a certain timeframe? Only use labs from previous encounter when the patient has an established diagnosis of CKD and looking to determine stage? Do you just use labs or do you use previous diagnosis or documentation of baseline?
  • lolly102412lolly102412
    I used the previous record in order to support "recent MI" on the current admission in order to establish the timeframe for the MI and wrote a query based on the information I found. I was glad to see the new AHIMA guidelines and find it very helpful in supporting previous diagnoses, as well as supporting the stages or timing of a current diagnosis.  
Sign In or Register to comment.