clinical indicator clarification

tpeytontpeyton
in CDI Talk Archive
Good morning everyone -
I am wondering if anyone has a good clarification for documentation of clinical indicators of a diagnosis and would be willing to share.

Thanks,
Tracy M. Peyton RN, CCDS
tpeyton@brmc.com

Comments

  • robert.hodges2robert.hodges2
    edited May 2016
    I'd like to see one too if someone has one. I don't see one in the forms and tools library on the ACDIS site.



    Robert



    Robert S. Hodges, BSN, MSN, RN, CCDS

    Clinical Documentation Improvement Specialist

    Aleda E. Lutz VAMC

    Mail Code 136

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  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited May 2016
    There were a couple of examples in Dr Kennedy's presentation from the
    conference:
    2013 Conference, Track 5: A Review of Coding Clinic for ICD-9-CM: CDI
    Highlights

    ● Documentation: Four-year-old child sustains a cautery injury to
    upper lip during maxillofacial surgery. Silvadene and dressing is
    applied to the affected area at the completion of the procedure and
    plastic surgery was consulted. The surgeon documented in the operative
    report that there were “no intraoperative complications.”
    ● Query: Please review the operative note notation of “a cautery
    lesion to the upper lip,” subsequent treatment with Silvadene, and
    clarify your documentation of “no intraoperative complications.”

    and:

    ● Documentation: Laboratory finding of serum sodium of 120 mmol/L and
    the attending physician documents hypernatremia in the final diagnostic
    statement.
    ● Query: Please review the laboratory section of the present record
    to confirm your discharge diagnosis of hypernatremia. Laboratory
    findings indicate a serum sodium of 120 mmol/L.

    I also really like the concept to consider the format option yes/no
    queries -- though don't have an example / suggestion to provide (thought
    there was a couple at the conference ... might have been the CDI ICD 10
    Boot camp which is not with me to check).

    Don

    =================
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    We have a generic query used to 'confirm'. I am trying to attach.


    Paul
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    There was a good one on the ACDIS blog recently

    http://blogs.hcpro.com/acdis/2013/04/qa-query-options-for-lack-of-clinical-indicators/


    “Dear Dr. Ericson, The diagnosis of bronchitis appears in the medical record (put the location). The patient is also receiving Zithromax presumably for the bronchitis. In the next progress note or the discharge summary can you please confirm the diagnosis of bronchitis by reiterating its associated clinical indicator(s) or state if it has been ruled out?”

    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

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