query for shock

judithbatesjudithbates
in CDI Talk Archive
Does anyone have a standard query for shock. I am particularly interested in hypovolemic/cardiogenic shock. We are frustrated with the lack of documentation with patients that on on pressors...IE, p/o patient with ongoing hypotension. Physicians keep documenting "ongoing hypotension". HELP!!!

Comments

  • Unknown
    edited May 2016
    Tracey,
    Here is some verbiage I used recently. Maybe you can find something useful in it.


    Could you render your opinion as to the clinical significance , if any, and the diagnosis being treated in this patient ?

    - not clinically significant -hypotension
    - Hypotensive shock -other more appropriate diagnosis
    The medical record reflects the following clinical findings:.
    Respiratory distress with RR in the 40’s
    B/P started to drop in the low 100s and then 70s
    She was placed on Levophed
    BUN = 41 creat = 2.9; she is anuric at this time

    Charlene
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