query for cerebral edema and brian compression?
We are trying to improve our SOI/ROM for our SDH's. I am trying to create a template to query for cerebral edema, brain compression, herniation, etc.
Our MD's greatly prefer queries with check boxes (of course!).
Is it appropriate to simply state, for example, that the pt was dx with a SDH and the physician has confirmed mass effect and midline shift and to ask if any of the following dx apply and are clinically significant (followed by check boxes)? Or would that be leading?
I dont know why I find this query so difficult, but I find that I am hesitating on what is appropriate. Our queries ARe a part of the permanent record, if that is relevant.
I would appreciate any advice.
Thanks,
Katy
Our MD's greatly prefer queries with check boxes (of course!).
Is it appropriate to simply state, for example, that the pt was dx with a SDH and the physician has confirmed mass effect and midline shift and to ask if any of the following dx apply and are clinically significant (followed by check boxes)? Or would that be leading?
I dont know why I find this query so difficult, but I find that I am hesitating on what is appropriate. Our queries ARe a part of the permanent record, if that is relevant.
I would appreciate any advice.
Thanks,
Katy
Comments
Journal. You will find everything you need in Oct Article.
Paul Evans, RHIA, CCS, CCS-P
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739