Organism specified Pneumonia

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in CDI Talk Archive
Hello Fellow CDS's

It is difficult to get an organism specified Pneumonia from our physicians because they do not feel the respiratory cultures or sputums are reliable. Querying for the bacterial type usually get a no response even if you give the possible, probable senario. Does anyone have any suggestions that may help us get better documentation for pneumonia?

Carla Heyn, RHIT, BS
CDS

Comments

  • robert.hodges2robert.hodges2
    edited May 2016
    When I query for pneumonia I usually ask what type they suspect or that they are treating. I've had long discussions with my providers and they see my point since most bacterial pneumonia's use more resources to care for the patients. I may not always get a specific such as gram negative, but I can usually get a "likely bacterial pneumonia" which is better than just unspecified.

    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
     
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    "We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley
  • mistercwmistercw
    edited May 2016
    How about phrasing a query in terms of the abx being used? You might say: Dear MD, what is the likely or suspected target organism for antibiotic XXXX?

    Chris
  • cmclose@saintfrancis.comcmclose@saintfrancis.com
    edited May 2016
    I query for what the possible/suspected organism of the pneumonia being
    treated by _______antibiotic (ie Clindamycin, Cefepime). Rarely is there
    a sputum culture done here unless pt is in PICU/vented/trached.

    Claudine Hutchinson RN
    Clinical Documentation Improvement Specialist
    Children's Hospital at Saint Francis
    Email: chutchinson@saintfrancis.com
    Office: (918) 502-6603
    Pager: 98-1001
  • annnd2009@gmail.comannnd2009@gmail.com
    Here is a great article that we attach to our queries to make them more comfortable writing, (in addition we obtained our antibiogram from our pharmacy and attach as well):
    possible/probable gram negative pneumonia
    especially if they have written HCAP or HAP and list the antibiotic choices

    http://www.acphospitalist.org/archives/2011/05/coding.htm

    Some times I think it seems too ambiquous I feel these two things make them more comfortable, although it has taken some time.
    Ann
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