Blood product utilization

julie.cruz-sjejulie.cruz-sje
in CDI Talk Archive
Hello, I am very new to CDI (march of this year). Our surgeons have requested any information regarding the utilization of blood products and documentation of their usage. Other than documenting "acute blood loss anemia" post-op and very specific doucumentation regarding "excisional" procedures, I'm not sure what other specifics may be required of them in the surgical setting.

I've already looked in ACDIS physician education tools, but looking for something a little more specific. Any thoughts or is there really nothing more specific required??

Thanks!

Julie Cruz, RN, CDS
St. Joseph Hospital
Eureka, CA 95501

Comments

  • dvitalone1dvitalone1
    edited May 2016
    Welcome to the wonderful world of CDI!!!


    LIFE IS TO SHORT ....STOP AND SMELL THE FLOWERS
    Dawn M. Vitalone, RN
    Clinical Documentation Improvement Specialist





  • tdavistdavis
    I find that for our surgeons it's alot of reminding for complications vs expectd events of surgery. It took a while for our doctors to understand that acute blood loss anemia is not considered a comlpication unless it is stated as such. When I first started I use to tell them that they would need to educate me as much as I would them. They also have a difficult time if we query on something that is outside their realm - i.e. CKD staging, suspected organisms with pneumonia, etc. If the consulting doesn't document it, then it is ultimately their patient and they will get queried by the coders. Hope this helps, and congrats on your new position in the realm of CDI.
    Theresa Davis BSN, RN, CCDS
    Eastern Maine Medical Center
  • tpeytontpeyton
    edited May 2016
    Hi,
    Welcome to the CDS profression. They should also be instructed as to the core quality measures required for SCIP. We also see alot of malnutrition forms here.
    Good luck!

    Tracy M Peyton RN, CCDS
    Case Management
    814-558-0406






  • paxnerospaxneros
    edited May 2016
    Are you asking how to pull a report on blood usage for them? (I wasn't sure if I was reading something different into your question.)

    Our Coding Department captures any transfusion through coding.

    Code 99.04 - Packed Cells, Code 99.05 -platelets, 99.07 - plasma, 99.03 - Whole blood

    We code and capture them for severity. You may try using that info. to pull reports. Also the charge master may have the reg. Code you could pull a report.

    NBrunson, RHIA, CCDS


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