Med sheets

nursronnam

I just received some feed back from one of our coders that said we should be asking for diagnoses that correlate with all the medications. It is my understanding that we can not query on something that is so vague? How do you all handle this?

Ronna

Ronna Mahlen RN, BSN | Manager of Clinical Documentation | Clinical Documentation Overlake Hospital Medical Center |
1035 116th Ave NE Bellevue WA 98004
425-467-3811 Phone | 425-941-0502 Cell| Ronna.Mahlen@overlakehospital.org

robert.hodges2

Fortunately my coders don't ask that question, but I do use that medication list to look for potential new diagnoses that are being treated but not documented, for example IV antibiotics with no mention of infection or IV medications such as Lasix without a clear link to a diagnosis.

In those cases I ask what is being treated and if it is impacting the patient's current condition.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
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Saginaw MI 48602
 
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mannb1

If I see medications specific to a disease/condition and that condition is currently being treated, I will query, but not if the provider indicates the condition is "stable" or "not significant @ this time" or something similar, which leads me to believe that this is how patient always looks - nothing acute going on.

dallend@einstein.edu

There should be a diagnosis listed for all medications. You can query for that - that patient is being treated for a condition. If you review the AHIMA practice brief you will see that it would be a valid query. We do not query for all medications - I do not query for meds such as stool softeners, etc. I focus more on CHF, COPD.

sbeatty

We query. As our organization moves to computerized physician order
entry, it will be a required field. No diagnosis, no order acceptance by
the software.

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Sandy Beatty, RN, BSN, C-CDI
Clinical Documentation Specialist
Columbus Regional Hospital
Columbus, IN
(812) 376-5652
sbeatty@crh.org

"The most important thing in communication is to hear what isn't being
said." Peter F. Drucker

dog

Haven't been asked by the coders, but I use the med sheets to support my queries. For instance, if they're on po Lasix at home but we order it IV, that helps (along with other clinical data) support a query for acute on chronic HF.

Seems like it ought to be the pharmacists requiring a diagnosis with the med orders.

Renee

Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital

nbrunson84

As a coder I reviewed meds to support diagnoses and likewise use it for CDI. It could mean a Chronic S/D Heart Failure - CC - if I need one. I don't usually like to Query on the medication alone - it's a good verbal query question for physicians if I see them - "Why is Mr/Mrs. Jones taking Lasix?"

cbarnes

I do the same.

Unknown

What type of software do you use? We have Meditech and I am being told
this may not be possible with our system.

Lisa Taylor, RN
CDI
Wooster Community Hospital

sbeatty

We don't have EMR for the physician documents yet. It's being spec'ed and bidded now, and this is a capabilty we are requesting.