Encephalopathy Query?

ggoodman@virginiahospitalcenter.comggoodman@virginiahospitalcenter.com
edited May 2016 in CDI Talk Archive
When do you query for Encephalopathy?

Do you query every time a Doc writes AMS?



What about the following circumstances...

1) AMS due to CVA

2) AMS due to seizure

3) AMS due to UTI

4) AMS due to drug overdose

5) AMS due to CA with mets to brain

6) AMS due to alcohol withdrawal



Etc.....





And of course sometimes you just get AMS with no due to.











Greta Goodman

Clinical Documentation Improvement Specialist

Health Information Management

Virginia Hospital Center

1701 North George Mason Drive

Arlington, VA 22205

703-558-5336

ggoodman@virginiahospitalcenter.com

Comments

  • dsmith12h@aol.comdsmith12h@aol.com
    edited May 2016
    I just had one of these myself. I went to "forms and tools" and found a query for AMS. I had to edit it to fit my need but you can probably do the same.


  • paxnerospaxneros
    edited May 2016
    Our Query covers the following indicators: Uremia, fever, infection, Sepsis/SIRS, Electrolyte imbalance, Hepatic failure, Abnormal Labs (with a blank for you to fill in), and Drug Toxicity (and a blankto list drug(s).

    We then offer the choices of Encephalopathy, NOS, Metabolic E., Toxic E., Hepatic E., and Hypertensive.

    I try to look at the patients whole picture and not query every AMS. Currently I am not having problems w/getiing Enceph. Documented but the underlying cause! So I have had to come up with an "underlying cause" query!

    Feast or famine...


  • paxnerospaxneros
    edited May 2016
    I also list an Other and Undetermined choice as well...

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