CDI in the ER

vanessa.falkoffvanessa.falkoff
in CDI Talk Archive
Hi everyone,

If you had ten minutes with your ER Docs, what would you discuss with
them?
Thanks in advance!

Vanessa Falkoff, RN
Clinical Documentation Coordinator
University Medical Center
(702) 383-7322
vanessa.falkoff@umcsn.com

Comments

  • sanchesanche
    edited May 2016
    respiratory failure for sure. Did you just start CDI in the ER?

    Chris Marcus-Sanchez, RN, RHIT, CCS
    Clinical Documentation Coordinator
    Health Information Management
    Holland Hospital
    (616) 394-3581
    Sanche@hollandhospital.org
  • cstukenbergcstukenberg
    edited May 2016
    Documentation to support present on admission -signs, symptoms, including documentation of other diagnosis that may be present this admission but not necessarily the primary problem. Ie wound issues.
  • sharon.colesharon.cole
    edited May 2016
    ABGs.
  • cynthia.a.goeweycynthia.a.goewey
    edited May 2016
    I too would talk about respiratory failure, lab interpretation with diagnosis' and not just the lab value, sepsis/SIRS as they often stabilize the pt in the ED with fluids, abx, anti-pyretics, etc...especially when the pt is there for several hours.
    Cindy
  • Unknown
    edited May 2016
    Present on admission - Sepsis, Acute respiratory failure

    Tracey Carey RN
    Clinical Documentation Specialist II
    Office 686-7421
  • dvitalone1dvitalone1
    edited May 2016
    We had a half hour with our main ER doc.
    We discussed several things:
    1. We asked them to document clearly on whether a Foley was in place upon arrival to ER
    2. Not to use symptoms as primary admitting ER Dx but to make sure the presenting symptoms are clearly documented.
    3. When they document "CHF" or "COPD" as primary admitting ER Dx to make sure they document acute or exac

    We have have 1 follow up visit with him and we have seen all the above being done.
  • vanessa.falkoffvanessa.falkoff
    edited May 2016
    Chris,
    I just started CDI for the whole facility in Feb :)
    v
  • Unknown
    edited May 2016
    Good Luck Vanessa

    Tracey Carey RN
    Clinical Documentation Specialist II
    Office 686-7421
    TTCarey@UAMS.edu
  • dvitalone1dvitalone1
    edited May 2016
    Tracey,
    What is a Clinical Documentation Specialist II ?
  • digardskdigardsk
    edited May 2016
    "insufficiency"...in general lose that term! Especially with renal issues. No "urosepsis".
  • sabullocksabullock
    edited May 2016
    Coma instead of just a low GCS rating. Let us know how this works out.

    Shelia Bullock, RN, BSN, MBA, CCM, CCDS
    Director, Clinical Documentation Improvement
    University of Mississippi Health Care
    2500 North State Street
    Room H139
    Jackson, MS 39216
    T: 601-815-3079 P: 601-815-3079 F: 601-815-9505
    sabullock@umc.edu
    umhc.com
  • dvitalone1dvitalone1
    edited May 2016
    IT IS HARD ENOUGH TO GET PRIMARY DOCS AND NEUROLOGISTS TO WRITE THIS LET ALONE ER MDs.
  • tpeytontpeyton
    edited May 2016
    Amen to the no UROSEPSIS...starts in the ER and primary docs follow suit.

    Tracy M Peyton RN, CCDS
    Case Management
    Bradford Regional Medical Center
    Upper Allegany Health Systems
    116 Interstate Parkway
    Bradford, PA 16701
    814-558-0406
  • robert.hodges2robert.hodges2
    Making sure they include all diagnoses being treated and evaluated. Not just listing that one primary reason the patient came to the ER. I know the others will impact their medical decision making, so they should take credit for evaluating them.

    Good luck!

    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
  • vanessa.falkoffvanessa.falkoff
    Thanks so much for the help and the good wishes!

    Vanessa
  • mary.mcgrady@accuityhealthcare.commary.mcgrady@accuityhealthcare.com
    Respiratory failure and respiratory insufficiency - acute and chronic
    Syncope and chest pain - not use symptoms when possible


    We are exploring placing a clinical documentation specialist in our emergency department. Do you currently include the emergency department review in your program? If so, what are the most common queries?
  • mannb1mannb1
    I would ask that they not use the blanket term "well nourished" for everyone. Many patients are malnourished, have cachexia, etc., and if the ER docs could make mention of this @ admit, I think that would be very valuable.

    Good Luck!
    Becky Mann, RN,CDS
    Sutter Solano Medical Center
    Vallejo, CA
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