Heading to Surgical Unit

ginpinginpin
in CDI Talk Archive
I am heading to the Surgical Unit as part of a rotation and I need your input! Besides Sepsis, Acute Blood Loss Anemia, Bowel Obstruction, or perforation, what other dx or conditions do you frequently query for? Are there any specific things that you look for in the record that stand out. Please any information will be greatly appreciated.. Thank you

Regina McCroskey BSN
Munroe Regional Medical Center
Ocala, Fl. 34478
351-401-8422

Comments

  • digardskdigardsk
    edited May 2016
    watch for: atelectasis, ileus beyond the normal expected (treatment rendered), wound infections/issues, UTI (poa? cath related?), medical issues that might arise in a stressed surgery patient (b/p, blood sugar)
  • Unknown
    edited May 2016
    Also, PNA...hypostatic, aspiration...depending on how debilitated the pt and how long the surgery.
  • digardskdigardsk
    edited May 2016
    respiratory failure (intubation beyond the norm), acute renal failure and other renal issues, COPD exacerbation, BMI issues with supporting documentation (extended OR time), nutrition issues
  • paxnerospaxneros
    edited May 2016
    Surgeons are notorious for keeping documentation strictly regarding the surgery at hand.

    We query for Comorbids - especially Heart Failure. Be prepared to defend your query- most physicians do not understand why we query for something that is not exacerbated or not "treated" within the admission.

    I explain to them that this captures the SOI/ROM of that patient which looks good for their report cards.

    We also look for HypoNa+.

    And the BIG one: Excisional Debridement.

    I also try to get clear underlying cause of those wound patients ( Diabetic Peripheral Neuropathy, Diabetic Peripheral Vascular, etc.) It really helps your coders out.

    If your hospital performs Gastric Bypass you need to look into BMI/malabsorption.

    NBrunson, RHIA, CCDS
  • digardskdigardsk
    edited May 2016
    Make sure you think it is beyond the expected before you ask. Depends on the types of surgeries you will be seeing. For instance, you expect the post heart surgery patient to be on the vent post-op prior to weaning. You don't expect the cholecystectomy patient to be on the vent. Discuss with your patient care (ICU) nurses what they usually see in your hospital with your surgeons. There might be a coding clinic on post-op resp failure?

    Ileus - look for the institution of treatment or a prolonged LOS. NG inserted or re-inserted? Meds started to promote return of bowel function. When I am not sure, I have found the surgeons approachable about what they expect to see for ileus with the surgery they performed.

    Sometimes surgeons are more accepting if you include guidance on and expected outcome. For instance, some surgeons will more readily write "expected acute blood loss anemia".

    Don't forget to review ANESTHESIA NOTES. They often note co-morbids, EBL, etc.
  • dbutlerdbutler
    edited May 2016
    One of the areas of specific concern for the surgical population is looking for and identifying surgical complications (of which there are a number) as well as surgeries that are performed as a result of a device complication or of a previous surgery. Finally, is looking carefully at the use of the phrase "post-op" -- in the surgeon's mind that might just as easily be a temporal relationship (occurred during the post surgical time frame) and not intended to mean a complication or causation. Also look for acute phases of chronic conditions that might flare up due to the physiological changes and stresses of surgery.

    Debridements also might be a more common issue -- depends on who does them most often and where those patients are found for your organization.

    There were a couple of very good presentations at the 2011 conference -- look in the forms and tools library for those ppt presentations. As I recall, there are also several blog posts and I believe Journal articles that are relevant -- focus both on specific conditions as well as more broadly on surgical complications. Unfortunately, don't remember the specifics to point you toward.

    Don
  • tpeytontpeyton
    edited May 2016
    Speaking of BMI does anyone else have difficulty getting the docs to write supportive notes for this? I usually have no trouble with the low BMI but the over 40 is a challenge. Our coders will not pick this up easily either.

    Tracy M Peyton RN, CCDS
    Case Management
    Bradford Regional Medical Center
    Upper Allegany Health Systems
    116 Interstate Parkway
    Bradford, PA 16701
    814-558-0406
  • cmclose@saintfrancis.comcmclose@saintfrancis.com
    edited May 2016
    Even harder on children~ having difficulty getting away from FTT and
    moving towards Malnutrition!

    Claudine Hutchinson RN
    Clinical Documentation Improvement Specialist
    Children's Hospital at Saint Francis
    Email: chutchinson@saintfrancis.com
    Office: (918) 502-6603
    Pager: 98-1001
  • mark.domineseymark.dominesey
    edited May 2016
    Actually, my experience is the opposite! It is much easier for me to get a physician to write the diagnosis of "obesity" or "morbid obesity" to correlate with the BMI over 40 (either one is needed in order to capture the CC of the >40 BMI). I find it VERY difficult to get them to write a diagnosis for the >19 BMI (also coded as a CC if a diagnosis is written for this finding).

    To carry this discussion further, which diagnoses are folks getting when querying for a diagnosis for the low BMI?

    Mark Dominesey, RN/BSN, MBA
    Clinical Documentation Specialist
    Martha Jefferson Hospital
    Charlottesville, VA
  • katysuegood@gmail.comkatysuegood@gmail.com
    I had this happen today! I had a pt with a BMI of 17 with a Pdx of pancreatic cancer.

    The response to the query was "underweight". Ha! thanks doc!
  • dbutlerdbutler
    edited May 2016
    I am a bit confused about some of these responses.
    Take advantage of the AHIMA query guidance and offer a menu of choices that are clinically reasonable (malnourished, cachexia, underweight) and be sure to include Other___________ and clinically indeterminable. Could even add an option for this did not affect clinical care (though would not if there was dietary consult, special nutrition supplied, etc.).

    Don
  • cynthia.a.goeweycynthia.a.goewey
    edited May 2016
    Our coders will code the bmi with a diagnosis of underweight.
  • tpeytontpeyton
    edited May 2016
    Our docs will write the obesity, morbid obesity usually without a query anymore but the coders want more than that and the bmi documented...it is frustrating.

    Tracy M Peyton RN, CCDS
    Case Management
    Bradford Regional Medical Center
    Upper Allegany Health Systems
    116 Interstate Parkway
    Bradford, PA 16701
    814-558-0406
  • sharon.colesharon.cole
    edited May 2016
    They can get the BMI from the dietician's note to pair with morbid obesity/obesity.
  • robert.hodges2robert.hodges2
    In our electronic record when providers import vital signs into the note it also automatically imports the calculated BMI. The challenge then becomes getting a diagnosis to go along with the BMI that is in the note, but we will normally query based on the documented BMI. A nice little opportunity we put into place here to capture these diagnoses.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
  • dbutlerdbutler
    edited May 2016
    Absolutely -- importing as part of a standard set of data (vital signs)
    is a wonderful way to use the power of an EMR.

    It seems to me that one of the issues in being able to capture and code
    the BMI falls under this definition of a reportable other diagnosis.
    Per the coding guidelines, one needs to have evidence of
    For reporting purposes the definition for “other diagnoses” is
    interpreted as additional conditions that affect patient care in terms
    of requiring:
    clinical evaluation; or
    therapeutic treatment; or
    diagnostic procedures; or
    extended length of hospital stay; or
    increased nursing care and/or monitoring

    The documented evidence to support one of the conditions above seems
    often to be the issue of concern often times when considering reporting
    the BMI, in addition to having the related diagnosis.

    Don
  • paxnerospaxneros
    edited May 2016
    That's where out BMI is located.

    We don't have too many issues with the obesity diagnosis being documented except that sometimes the physician's idea of "morbid" and the BMI do not match.

    Malnutrition is another case altogether. Our Nephros are all over the Malnutrition documentation but our other physiciians struggle with this diagnosis.

    NBrunson, RHIA, CCDS
  • Unknown
    edited May 2016
    On occasion our physicians definition of morbid obesity do not match ICD-9 criteria. I have struggled with the computer generated BMI documentation (which our coders take). I do not use it unless the dietician documents as the computer generated does not always match the dietician BMI (when there are both).

    Our nephrologists also freely document malnutrition but fail to add specificity. So queries are placed for type and severity.

    Charlene
  • dsmith12h@aol.comdsmith12h@aol.com
    edited May 2016
    The only problem I have with the computer calculation of BMI is if it calculates correctly for those patient's who are pregnant or have missing limbs. I have been told that the BMI calculation in our system does not take this into account. Our BMI is not auto-populated into the the body of the EMR. 
  • lisa.schuellisa.schuel
    I will be out of the office on until Tuesday, June 21st. I will respond to your email when I return. Thank you.
  • mark.domineseymark.dominesey
    edited May 2016
    Another thing to be very careful with BMi is if someone is currently in an fluid overload status (CHF, anasarca, full on edema). The auto-BMI will not correct for that was well. Here is where our clinical judgment and experience come into play.


    Mark Dominesey, RN/BSN, MBA
    Clinical Documentation Improvement Specialist
    Health Information Management Services
    Martha Jefferson Hospital
    459 Locust Ave
    Charlottesville, VA 22902
    Mark.Dominesey@mjh.org
  • robert.hodges2robert.hodges2
    edited May 2016
    Great point Mark. I look at trends over time to see if this is new or
    chronic as well as the clinical diagnosis. If there an amputation is
    documented or if there are any other questions I look for the
    dietician's notes for an accurate BMI.


    Robert


    Robert S. Hodges, BSN, MSN, RN, CCDS
    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 difference between the right word and the almost right word is the
    difference between lightning and the lightning bug." Samuel "Mark Twain"
    Clemens
  • mark.domineseymark.dominesey
    edited May 2016
    I actually had a patient in ARF on top of CKD, came in after two weeks of no urination; we took 8 liters off of this guy! Hmm, ~7.5lbs per gallon water x 2 gallons =~ 15 lbs! Enough to drop someone out of a BMI >40 by several lbs! (no wonder he had dyspnea)

    Mark
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