RE: Pdx selection: sepsis
Hi Katy,
I would still stick with the sepsis as the acute issue that caused this admit.
Have a great week!
Vanessa Falkoff RN
Clinical Documentation Improvement Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
Compassion * Accountability * Respect * Integrity
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Monday, February 15, 2016 1:02 PM
To: Vanessa Falkoff
Subject: [cdi_talk] Pdx selection: sepsis
I have a patient with underlying CHF with end-stage cardiomyopathy, ESRD, diabetes, liver disease, malnutrition with numerous stage 3/4 decubes, with hx of numerous hospitalizations and surgeries that came in with shock. This was immediately thought to be cardiogenic but possibly some component of septic shock as well. No source was identified until 5 days in when we had a positive c-diff culture. The entire time he was on antibiotics however ultimately treatment was deemed medical future because of his multiple organ failures and underlying chronic illnesses (not assoc with sepsis).
I had sepsis sequenced as primary per guidelines until I got to the DCS. It states:
Antibiotics were given for possible infection and several cultures were positive, however, Mr. Benally's primary clinical issue was his end stage cardiomyopathy plus end stage renal and hepatic disease. After antibiotic therapy, on 1/30/2016, after multiple family conferences, pressor and inotrope support were removed as he had failed to wean and there were no interventions that were reasonably to be offered for end stage multi system organ failure.
Would you stick with sepsis as pdx or does this change the Pdx selection in your opinion?
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
I would still stick with the sepsis as the acute issue that caused this admit.
Have a great week!
Vanessa Falkoff RN
Clinical Documentation Improvement Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
Compassion * Accountability * Respect * Integrity
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Monday, February 15, 2016 1:02 PM
To: Vanessa Falkoff
Subject: [cdi_talk] Pdx selection: sepsis
I have a patient with underlying CHF with end-stage cardiomyopathy, ESRD, diabetes, liver disease, malnutrition with numerous stage 3/4 decubes, with hx of numerous hospitalizations and surgeries that came in with shock. This was immediately thought to be cardiogenic but possibly some component of septic shock as well. No source was identified until 5 days in when we had a positive c-diff culture. The entire time he was on antibiotics however ultimately treatment was deemed medical future because of his multiple organ failures and underlying chronic illnesses (not assoc with sepsis).
I had sepsis sequenced as primary per guidelines until I got to the DCS. It states:
Antibiotics were given for possible infection and several cultures were positive, however, Mr. Benally's primary clinical issue was his end stage cardiomyopathy plus end stage renal and hepatic disease. After antibiotic therapy, on 1/30/2016, after multiple family conferences, pressor and inotrope support were removed as he had failed to wean and there were no interventions that were reasonably to be offered for end stage multi system organ failure.
Would you stick with sepsis as pdx or does this change the Pdx selection in your opinion?
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: vanessa.falkoff@umcsn.com
If you would like to be removed from CDI Talk, please send a blank email to
leave-cdi_talk-12881172.0567913f3a65957e70b98241bedfe64e@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
Comments
Mary L. Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
740-689-4443
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, February 16, 2016 10:53 AM
To: Mary Snook
Subject: RE:[cdi_talk] Pdx selection: sepsis
Hi Katy,
I would still stick with the sepsis as the acute issue that caused this admit.
Have a great week!
Vanessa Falkoff RN
Clinical Documentation Improvement Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
Compassion * Accountability * Respect * Integrity
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Monday, February 15, 2016 1:02 PM
To: Vanessa Falkoff
Subject: [cdi_talk] Pdx selection: sepsis
I have a patient with underlying CHF with end-stage cardiomyopathy, ESRD, diabetes, liver disease, malnutrition with numerous stage 3/4 decubes, with hx of numerous hospitalizations and surgeries that came in with shock. This was immediately thought to be cardiogenic but possibly some component of septic shock as well. No source was identified until 5 days in when we had a positive c-diff culture. The entire time he was on antibiotics however ultimately treatment was deemed medical future because of his multiple organ failures and underlying chronic illnesses (not assoc with sepsis).
I had sepsis sequenced as primary per guidelines until I got to the DCS. It states:
Antibiotics were given for possible infection and several cultures were positive, however, Mr. Benally's primary clinical issue was his end stage cardiomyopathy plus end stage renal and hepatic disease. After antibiotic therapy, on 1/30/2016, after multiple family conferences, pressor and inotrope support were removed as he had failed to wean and there were no interventions that were reasonably to be offered for end stage multi system organ failure.
Would you stick with sepsis as pdx or does this change the Pdx selection in your opinion?
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404