Expected post-operative respiratory failure
I recently took on a new assignment reviewing ICU/progressive care charts. I see a lot of documentation of "Expected post-op respiratory failure" or "Expected AHRF" on post op or CABG patients who were successfully weaned within the 6 hours post-op. Any tips on how I should write a clarification?
Comments
This is a big topic of confusion. But it's my understanding that documentation of "Expected" diagnosis cannot be captured in Coding. That Respiratory Failure was "Expected" as part of the normal course for the patient, so no further clarification is needed. It's a little frustrating because even the documentation of "Expected" Acute Blood Loss Anemia cannot even be captured, and sometimes this leaves a CABG patient without a single CC/MCC.
At our facility, if the patient is extubated within 6 hours, we document "Acute Respiratory Insufficiency," while the patient is Intubated, and still waking up from sedation/and anesthesia.
Thank you so much for your response!