needing help composing a query
Hi, I think I need a vacation. I have gone blank! I need to write a query but need to do so without questioning physicians clinical judgement.
Senerio: patinet admited through ED for respiratory distress and was intubated due to increased WOB. Difficult intubation due to possible obstruction/tracheal stenosis and possible infectious process early, infiltrate seen on CT. ABG: pO2-143 & pCo2-25.9. Plan for Bronch., cultures ordered. empiric abx coverage x3.
The physician has rendered his diagnosis of resp. distress-- I do not want to question his clinical judgement but feel there may be a question of resp. failure here.
Is this a "when not to query" zone??
Debbie S
Senerio: patinet admited through ED for respiratory distress and was intubated due to increased WOB. Difficult intubation due to possible obstruction/tracheal stenosis and possible infectious process early, infiltrate seen on CT. ABG: pO2-143 & pCo2-25.9. Plan for Bronch., cultures ordered. empiric abx coverage x3.
The physician has rendered his diagnosis of resp. distress-- I do not want to question his clinical judgement but feel there may be a question of resp. failure here.
Is this a "when not to query" zone??
Debbie S
Comments
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
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Saginaw MI 48602
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I don't think asking the physician for a diagnosis is questioning their judgment...I think that's what we're supposed to do. You have a dx of distress and you're telling the physician that, given the fact that the pt was intubated, getting bronched, etc., that the dx doesn't accurately reflect the severity of illness. If you believe a patient meets criteria for a given diagnosis and the documentation isn't clear, then you need to query.
This is a good, basic article you might want to look at and share with your doc. I always like references that are at the peer level for the physicians:
http://www.acphospitalist.org/archives/2011/07/coding.htm
Renee
Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center
opinion, is there a component of failure present?"
Elizabeth Hynd RN, BSN, CPUR
Clinical Documentation Specialist
863-687-1100 ext. 7313
Dear Provider(insert name, of course).
Noted documentation of respiratory distress (or whatever they actually said) in the notes dated (insert dates). A review of the pertinent diagnostic information includes ABG values of (insert actual results) along with resources that included intubation and mechanical ventilation (also list every resource used [ICU placement, critical care protocols, etc.).
In light of the patient's presentation on admission and subsequent resources, in your clinical opinion does one (or more) of the following diagnoses provide a more specific diagnosis? If so, please add this clarification to your progress notes AND discharge summary:
Multiple choice options:
1) Respiratory distress/insufficiency only (I always give them the option of using their original diagnosis, even if it "stinks") so it doesn't look like I'm leading them to only the higher-weighted, higher severity diagnoses)
2) Respiratory failure, unspecified
3) Acute respiratory failure
4) Chronic respiratory failure
5) Acute and chronic respiratory failure
6) Other (please state) ________________________
7) Unable to determine additional specificity