Opinions please
I need some input on a case. Here's the scenario:
79 year old female presented for planned sigmoid resection for suspected
cancer. H&P states "h/o diverticular disease." Treated at another
facility prior to surgery for sigmoid lesion on CT. Inflammatory process
could not be ruled out. Treated with antibiotics and recovered.
Subsequent colonoscopy revealed sigmoid mass. Path report positive for
sigmoid carcinoma.
Anesthesia record documented diverticulitis. Clinical nutrition saw
patient x 3 and documented h/o diverticulitis. High fiber diet
recommended and ordered.
Documentation by attending surgeon was sketchy at best. Diverticulitis
was not mentioned again in record. The patient's LOS was on day longer
than bowel resection without cc.
We're debating about whether or not diverticulitis meets the UHDDS
criteria for a reportable secondary diagnosis. What do you think?
Cathy Seluke, RN, BSN, ACM, CCDS
Supervisor Clinical Documentation Compliance
MaineGeneral Medical Center
149 North Street
Waterville, ME 04901
Phone (207) 872-1796
Fax (207) 872-1519
Cathy.Seluke@mainegeneral.org
"That's why erasers were put on pencils."
--Robert Lovely c. 1960 when asked if he ever made
mistakes
79 year old female presented for planned sigmoid resection for suspected
cancer. H&P states "h/o diverticular disease." Treated at another
facility prior to surgery for sigmoid lesion on CT. Inflammatory process
could not be ruled out. Treated with antibiotics and recovered.
Subsequent colonoscopy revealed sigmoid mass. Path report positive for
sigmoid carcinoma.
Anesthesia record documented diverticulitis. Clinical nutrition saw
patient x 3 and documented h/o diverticulitis. High fiber diet
recommended and ordered.
Documentation by attending surgeon was sketchy at best. Diverticulitis
was not mentioned again in record. The patient's LOS was on day longer
than bowel resection without cc.
We're debating about whether or not diverticulitis meets the UHDDS
criteria for a reportable secondary diagnosis. What do you think?
Cathy Seluke, RN, BSN, ACM, CCDS
Supervisor Clinical Documentation Compliance
MaineGeneral Medical Center
149 North Street
Waterville, ME 04901
Phone (207) 872-1796
Fax (207) 872-1519
Cathy.Seluke@mainegeneral.org
"That's why erasers were put on pencils."
--Robert Lovely c. 1960 when asked if he ever made
mistakes
Comments
and if hx, would not use as a cc.
Karen McKaig, BSN, RN, CCM, CPUR
Case Manager
Clinical Documentation Specialist
Baxter Regional Medical Center
Mountain Home, AR 72653
870-508-1499
kmckaig@baxterregional.org