dx appearing in the H&P and prog notes but not on DC summary

leimapaloleimapalo
in CDI Talk Archive
Hi,

Just wondering what everyone else is doing about dx appearing in the H&P and prog notes but then does not show up in DC summary - code or not code?

Example:
Pt admitted under hospitalist for chest pain, SOB - dx COPD exacerbation, r/o MI. Admit to tele, trend trop, usual COPD exac tx cocktail, cards consult. Cardiology saw pt and noted NQWMI in his progress notes but Attending does not write this dx in his notes nor on the DC summary. But cardiology placed pt on medical mngt for MI - ASA, Bblocker, etc.

Wouldn't it be appropriate to code NQWMI as secondary condition?

Comments

  • kmckaigkmckaig
    edited May 2016
    We require Principal Diagnosis to be documented on DCS but other conditions, ie CC/MCC do not have to be as long as they are not contradicted in the DCS. If the Principal Dx gets left off, we go back to the Physician to clarify and get the DCS addended as necessary.


    Karen McKaig, BSN, RN, CCM, CPUR, CCDS
    Case Manager
    Clinical Documentation Specialist
    Baxter Regional Medical Center
    Mountain Home, AR 72653
    870-508-1499
    kmckaig@baxterregional.org
  • Unknown
    edited May 2016
    Speaking of discharge summaries...
    We are currently trying to update our physician bylaws to speed up the time that discharge summaries need to be completed by the physicians. Will you share your organization's time frame for when they need to be completed? Has this been an issue with your physicians since discharge summaries have a whole new sense of urgency thanks to the RACs?
    Thank you,

    Linnea Thennes, RN, BS, CCDS
    Supervisor, Clinical Documentation Improvement
    Centegra Health System
    815. 759-8193
    lthennes@centegra.com
  • wchenneywchenney
    edited May 2016
    I just wrote and instituted a new Dischg summary policy for our
    physicians. Dischg summaries must be completed within 72 hrs of dischg.
    It may be dictated 24 hours prior to dischg but a progress note and
    dischg order must be written on the day of dischg. All in patients must
    have a dischg summary except for patients whose stay are less than 24hrs
    and routine newborn stays. The dischg summary must include:

    Reason for hospitalization

    Procedures preformed

    Care, treatment and services provided

    Condition and disposition at dischg

    Provisions for follow-up care

    Final diagnosis(es) must be listed in order of principal and secondary
    diagnoses. Symptoms must not be used unless specified as undiagnosed.

    Hope this helps!!

    Wendy



    Wendy R. Chenney RN BSN
    Manager Clinical Documentation
    (440) 743-4533
    Fax: (440) 743-4552
    Pager: (440) 675-5929
  • vdavis2vdavis2
    edited May 2016
    Our HIT committee has made recommendations that a D/C Sum should be completed within 3 days of discharge as "best practice." This plays in to Meaningful Use and the pt being able to contain a completed record. Usually ours are completed the day of discharge, however we do still have some that wait until the 30 day mark!

    Vicki S. Davis, RN CDS
    Clinical Documentation Improvement Manager
    Health Information Management Department
    Alamance Regional Medical Center
    Office (336) 586-3765
    Ascom Mobile (336) 586-4191
    Fax (336) 538-7428
    vdavis2@armc.com

    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
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