chf vs TACO vs TRALI

tpeyton · July 2012

I have a 73 yo pt who has severe anemia/gib, hx chf, who during blood transfusion developed dyspnea/cp and cxr shows mild chf.
In your clinical opinions what would you clarify for?

Tracy M. Peyton
tpeyton@brmc.com

mdominesey · July 2012

Well the dyspnea is a symptom of something going on in the lungs, the CXR shows CHF (yes, interpreted as "mild"). I would still place my generic CHF query with the clinical indicators from the chart. I would also look for any reactions to the blood in the record.

Mark

Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Clinical Documentation Excellence
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Sibley Memorial Hospital
Information Technology
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Washington DC, 20016-2695
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dvitalone1 · July 2012

I'd also query for anemia specificity

katysuegood@gmail.com · July 2012

Are there any other indications of TRALI? Hypotension? Fever?
I would definitely Query on the specificity for CHF and anemia since that is clearly in the record. You could also query on the underlying cause of the CP/Dyspnea during the transfusion if it is unclear if CHF is the cause. If you have access to the DR, I also think this would be an appropriate time CHF was the cause or whether it was something else.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
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Cell: 928.814.9404

robert.hodges2 · July 2012

If you use a CHF query wouldn't you be leading? Personally I'd use my signs and symptoms query, include the CXR results, and simply ask for the clinical significance, if any, of the signs and symptoms. And if they are clinically significant, ask for the significance and cause of the signs and symptoms to be documented. And as someone else said, I'd also query for specificity of the documented anemia.

Just my thoughts.

Robert

Robert S. Hodges, BSN, MSN, RN, CCDS
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mdominesey · July 2012

CHF is already documented as hx and now in the CXR report. So fair game IMHO.

Mark

Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Clinical Documentation Excellence
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital
Information Technology
5255 Loughboro Rd NW
Washington DC, 20016-2695
W: 202.660.6782
F: 202.537.4477
mdominesey@sibley.org
http://www.sibley.org

tpeyton · July 2012

already did the anemia clarification

Tracy M Peyton RN, CCDS
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
814-558-0406

katysuegood@gmail.com · July 2012

Hmm... something magically was cut off in my response. It should say

"this would be an appropriate time for a quick conversation with the Dr to clarify if CHF was the cause"

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

katysuegood@gmail.com · July 2012

I was going on the assumption that CHF was already documented in the record. If not, I would just query for the underlying cause of the dypsnea/CP.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

tpeyton · July 2012

h/p already has ch systolic hf......that is why I was thinking acute.....but wasn't sure with happening during transfusion and transfusion was stopped. Doc unfortunatlely had already made rounds.

Tracy M Peyton RN, CCDS
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
814-558-0406

sharon.cooper@owensborohealth.org · July 2012

Agree

Sharon Cooper, RN-BC, CCS, CCDS, CDIP
AHIMA-Approved ICD-10-CM/PCS Trainer
Owensboro Medical Health System
Manager Clinical Documentation & Appeals
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robert.hodges2 · July 2012

Because you are unsure of the cause of the symptoms, I would still query on the signs and symptoms and ask for the underlying cause to be documented. It may very well be an acute exacerbation of the CHF related to fluid overload from the transfusion, but it could also be a transfusion reaction. Best for the provider to clarify than assume a cause or lead a provider to a diagnosis.

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

mdominesey · July 2012

There is enough evidence to just query for a clarification of the CHF that is already documented. It is in HX and now documented in the Radiology report. The query would not lead the doc to say that the particular cause of the dyspnea is CHF, merely to ask for a clarification of the non-specific diagnosis that is already documented.

I would not hesitate to place a CHF query based on this evidence. I would also place an additional query asking for a cause and effect of the current problem with acute CHF being but one option with "None" and "Unable to determine" being additional options.

Mark

Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Clinical Documentation Excellence
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital
Information Technology
5255 Loughboro Rd NW
Washington DC, 20016-2695
W: 202.660.6782
F: 202.537.4477
mdominesey@sibley.org
http://www.sibley.org

evanspx@sutterhealth.org · July 2012

Agree - asking attending to comment on the CHF noted in Rad report should be acceptable. Rule in - rule out - state other cause - unable to determine - no CHF, no overload - other acceptable responses ensuring compliant query.

Request for Clarification or Confirmation Of Radiology Findings

Dear Physician/PA/NP: __________________________________________________________________ or other responsible provider:
For accurate coding and severity-of-illness compilation, this query is directed to you. When responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.

Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not reported unless an authorized provider indicates their clinical significance.

The Radiologist has identified on ________________ (DATE) in the __________________________ (TYPE OF EXAM)

The Diagnosis : _____________________________

Please validate this diagnosis.

CDI Specialist/Coder: _________________________________ Date:_____________ Time: _______________

Physician/PA/NP Response:

CONFIRMATION:

0 I concur with the Radiologist Findings
0 I do not concur with the Radiologist Findings
0 Cannot be determined

CLARIFICATION of findings: Please document any SPECIFIC diagnosis or pathology associated with these Radiology findings.

0 Diagnosis/Pathology: ______________________________________________

0 No clinical significance

0 Cannot be determined

Physician/PA/NP Printed Name:___________________________________________________________________

Physician/PA/NP Signature: __________________________________________ Date: __________Time:_______

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

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
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chf vs TACO vs TRALI

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