Fairly new to CDI

kwilliams@halifaxrmc.orgkwilliams@halifaxrmc.org
in CDI Talk Archive
Have a patient that was a surgical admission- attending surgeon. Hospitalist consultation for medical management. Nursing assessment found patient to have a sacral decubitus. Who would you query for the decubitus/POA?

Comments

  • ggoodman@virginiahospitalcenter.comggoodman@virginiahospitalcenter.com
    edited March 2016
    You could Query both the Hospitalist and the Surgeon!
    However, if you are only able to Query one, go with the Attending.
    GG

  • kerryseekircherkerryseekircher
    edited March 2016
    It would be appropriate for either to document the pressure ulcer. If the hospitalist's are following for medical management, you might want to start there, especially as they are typically easier to track down.
    Good luck!
    Kerry

    Kerry Seekircher, RN, BS, CCDS, CDIP
    Clinical Documentation Program Manager
    Northern Westchester Hospital
    400 East Main Street
    Mount Kisco, NY 10549
    Email: kseekircher@nwhc.net
    Phone: 914-666-1243
    Fax: 914-666-1013

    Celebrating 100 Years of Care in our community
    #NWH100YearsOfCare





  • kwilliams@halifaxrmc.orgkwilliams@halifaxrmc.org
    edited March 2016
    Thanks, Kerry. Would like to hear more responses if I can. I have an underlying agenda for this survey, please.

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Thursday, December 03, 2015 9:55 AM
    To: Williams, Kimberly
    Subject: RE: [cdi_talk] Fairly new to CDI

    It would be appropriate for either to document the pressure ulcer. If the hospitalist's are following for medical management, you might want to start there, especially as they are typically easier to track down.
    Good luck!
    Kerry

    Kerry Seekircher, RN, BS, CCDS, CDIP
    Clinical Documentation Program Manager
    Northern Westchester Hospital
    400 East Main Street
    Mount Kisco, NY 10549
    Email: kseekircher@nwhc.net
    Phone: 914-666-1243
    Fax: 914-666-1013

    Celebrating 100 Years of Care in our community #NWH100YearsOfCare





  • martin.conroymartin.conroy
    edited March 2016
    I find Hospitalist are the most likely to document response in the record

    Marty
    Temple

  • annnd2009@gmail.comannnd2009@gmail.com
    edited March 2016
    I think I'd go for hospitalist. Surgery probably consulted for them to address non-surgical issues. Lucky for you!! It would only matter for conflict and that is an unlikely issue. I can imagine a hospitalist (if the are exhausted by the process) could take the attitude -ask the attending-but I'd let them do so before asking surgery. If I did have to ask surgery is explain the course I had tried first.

    Ann

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited March 2016
    Depends greatly upon local protocol.

    Our facilities use Resident's, NPs and PA extensively, and all are authorized to independently answer a query - also, we have a Hospitalist 'follow' medical conditions for a majority of our surgical cases.

    Our reality is that our Surgeons expect 'someone else' to chart for them and they have actually stated their job is 'only' to perform surgery. Also, at a teaching site, the Resident is expected to dictate H&P, Summary, and be prime responder to query.

    Given our Hospitalist are receptive to quality initiatives, we may also chose to send to Hospitalist.

    Exception: If the Surgeon is the attending, we send issues of dissonance to the attending surgeon. I would not send the same query to two different providers, however, as this could create further conflict and also skew query and response rates.

    PE




    Paul Evans, RHIA, CCS, CCS-P, CCDS
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