patient problem list
Hello All!
Next question: Do any of you currently populate the patient problem list at your facility? And, do any coding departments code from the patient problem list? We are attempting to see if the CDS's populate the list, and the providers have to sign off as to wether they agree or disagree, what conflicts this will cause.
Thank You,
Susan Tiffany RN, CCDS
Supervisor Clinical Documentation Program
Next question: Do any of you currently populate the patient problem list at your facility? And, do any coding departments code from the patient problem list? We are attempting to see if the CDS's populate the list, and the providers have to sign off as to wether they agree or disagree, what conflicts this will cause.
Thank You,
Susan Tiffany RN, CCDS
Supervisor Clinical Documentation Program
Comments
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
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-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, March 08, 2011 11:34 AM
To: Hodges, Robert
Subject: [cdi_talk] patient problem list
Hello All!
Next question: Do any of you currently populate the patient problem list at your facility? And, do any coding departments code from the patient problem list? We are attempting to see if the CDS's populate the list, and the providers have to sign off as to wether they agree or disagree, what conflicts this will cause.
Thank You,
Susan Tiffany RN, CCDS
Supervisor Clinical Documentation Program
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We have been asked to see if, as RN's, we populated the problem list with
diagnosis we see in the record, and the providers reviewed and signed off
on them, if this would pose a conflict. I like the idea, as long as it
clearly states, which it does, the credentials of the person entering
data.
Thank You,
Susan Tiffany RN, CCDS
Supervisor Clinical Documentation Program
Guthrie Healthcare System
"Twenty years from now you will be more disappointed by the things you
didn't do than by the ones you did do. So throw off the bowlines. Sail
away from safe harbor.Catch the trade winds in your sails. Explore. Dream.
Discover." Mark Twain
problem list is part of that record. We have that here and our problem
lists are terrible because of duplication, for example chronic kidney
disease may be in there three times under three different names. We
have made providers accountable for maintaining the patient problem list
since they are the primary care providers.
My personal opinion is that even as a RN I would not presume to add to a
patient's problem list unless it was within my scope of practice. I may
ask a provider as a CDIS, and have, if they could review information and
if appropriate add it to the problem list, but it's not something I
would do even if I had access to do it. Like most things in life, the
provider is the one ultimately accountable for what is in the patient's
medical record.
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
The ppt also has some very interesting and exciting process and info as far as quality, safety and core measures.
We do not populate the problem list either.
Our coders will code from the problem list (since it generally is included in PN, HP, DCS) as long as there is evidence of tx, monitoring, etc. (the requirements to capture something as a valid ODX). A caveat, providers don't always keep the problem list up to date, so there are instances of an acute diagnosis (now resolved) that is carried over from a previous encounter, or of a dx that is recorded in the list as acute on chronic, but all tx and evidence points to chronic only.
Don
>>> "CDI Talk" 3/8/2011 11:37 AM >>>
Coders used to do it here, but no longer. Only providers are authorized to update the patients problem list. The issue was that a "non-clinical" person was making a clinical determination.
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
concerns with scope of practice, but I also agree with my providers when
they say that they want to have an accurate problem list, just don't have
time. If we could suggest diagnosis, "clean up " duplications, and
possible, in the future, use the problem list as a query .... I agree
completely that the provider has ultimate, final say on diagnosis's, or
difficulty is getting the correct verbiage out of them now .... would this
be the way to bridge the gap?
Thank You,
Susan Tiffany RN, CCDS
Supervisor Clinical Documentation Program
"Twenty years from now you will be more disappointed by the things you
didn't do than by the ones you did do. So throw off the bowlines. Sail
away from safe harbor.Catch the trade winds in your sails. Explore. Dream.
Discover." Mark Twain
advanced practice) to work as 'scribes'. The RN rounds with the
physician, examines the patients themselves, reviews records, etc. and
then has a detailed conversation with the physician about findings,
plans, etc. The nurse prepares HP, PN, etc that the physician then
reviews and cosigns.
In a similar way, I can see some space for a role for a non-physician
to assist to maintain and up date the problem list at the SPECIFIC
direction of the physician. My concern is for the perception of all
this when the role is filled by a CDS member, that there may be a drift
away from specific direction toward the risk of perceived leading.
Thus, I am resistant to the idea without extremely strong measures in
place. We all know there are physicians who pay less than complete &
careful attention to their responses and what they sign off in an
electronic record.
I wish we all had an easy, effective answer to this problem. Seems to
me we are all still searching for improved answers.
Don
This is a list of what has been coded and is seen by providers when they use this particular software- which most do- but is not what I would consider anfficial PL. That function has never been used.
NBrunson, RHIA,CCDS
CDI Talk wrote:
>Hello All!
>Next question: Do any of you currently populate the patient problem list at your facility? And, do any coding departments code from the patient problem list? We are attempting to see if the CDS's populate the list, and the providers have to sign off as to wether they agree or disagree, what conflicts this will cause.
>
>Thank You,
>Susan Tiffany RN, CCDS
>Supervisor Clinical Documentation Program
>---
>CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
>
>You are receiving this message as a member of CDI Talk as: paxneros@comcast.net
>If you would like to be removed from CDI Talk, please send a blank email to
>leave-cdi_talk-12570479.a1577b6c64e12fd218b1dd53efa7aa7f@hcprotalk.com
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>Copyright 2010
>HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945