Clinical umentation gold standards card by mikeholy

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									Clinical documentation gold standards card


            Clinical Documentation Gold Standards:
                  Document the patient's "reason for admission".
                  If the patient's "reason for admission" is a symptom, document the cause,
                   probable or possible, or differential diagnoses.
                  Document every condition that is impacting the patient's stay, including chronic
                   conditions.
                  Document the "clinical significance" of every abnormal test result in the patient's
                   record.
                  Queries may be responded to by the following: medical faculty, residents, nurse
                   practitioners, and physician assistants who have been credentialed through the
                   MUSC Medical Staff Office credentialing process.
                  All notes entered by medical students must be counter-signed by the attending
                   physician or the resident.
                  Coding rules prohibit use of ↑ ↓.
                  Diabetes must include type and be termed “controlled” or “uncontrolled” (no
                   other term can be accepted).
                  Radiology/Pathology/Laboratory report findings need to be referenced in the
                   progress notes.

                                  UHDDS General Rule
                            For Reporting Secondary Diagnosis
  A secondary diagnosis is any condition that is documented by the physician, and meets ONE of the
  following criteria:
                     1. Clinically evaluated
                     2. Therapeutically treated
                     3. Diagnostically tested
                     4. Causes an increase in LOS or nursing care

          Dear Dr: ________________________________ Date: ________________________

          MRN Number: ___________________________



         Document the findings in record.

                              If you do not agree, please check 


  PLEASE NOTE:

          Leave the query form in the chart.
          If you do not concur, please check box on the bottom of form.
          Please call XXX-XXXX with any questions.

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                                                                                           May 2005
                                                                                           Revised 6/06
                   Severity / Co-morbidities
            Secondary Diagnoses Impacting DRG Assignment
                  (This is not a complete list of co-morbidities.)

Acidosis – metabolic/respiratory        Addison's disease
Alcohol intoxication/withdrawal/abuse   Anemia- blood loss/aplastic
Angina pectoris                         Anorexia nervosa
Aorta aneurysm-rupture                  Ascites
Asthma – acute exacerbation             Asthma – status asthmaticus
Atelectasis                             Atrial fibrillation/atrial flutter
Bacteremia                              Bleeding esophageal varicies
Boils                                   Brachial neuritis
Bronchiectasis                          Bronchitis
Cachexia                                Cardiac arrest
Cardiomyopathy                          Cellulitis
CHF                                     Cholangitis
Cirrhosis                               Convulsions
COPD                                    Cor pulmonale, acute
Coronary ischemia                       Cystitis
CVA with cerebral infarction            Dehydration
Decubitus ulcer                         Diabetes, type 1 or II
Diabetes, "uncontrolled"                Drug dependence
Electrolyte imbalance                   Emphysema
Encephalopathy – anoxic                 Endometritis
Fecal Impaction                         Fluid retention




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                      Severity / Co-morbidities
              Secondary Diagnoses Impacting DRG Assignment
                       (This is not a complete list of co-morbidities)

GI hemorrhage                              Hallucinations
Heart block –AV/BBB/trifascicular          Hematemesis
Hematuria                                  Hemoptysis
Hemorrhage, cerebral, non-traumatic        Hepatitis
Hydronephrosis                             Hypernatremia/Hyponatremia
Hypertensive heart disease w/CHF           Hypoxia
Infected hydrocele                         Infective myositis
Leukopenia                                 Malnutrition
Melena                                     MI, acute (less than 8 weeks)
MVP                                        Mitral Regurgitation
Myocarditis, acute                         Neutropenia
Orchitis with abscess                      Pancreatitis, acute
Pancytopenia                               Paralytic ileus
Paroxysmal tachycardia                     Pathological fracture
Pericarditis, acute                        Peritonitis
Phlebitis                                  Pleural effusion
Pneumonia                                  Pneumothorax
Prostatitis, acute                         Pulmonary embolism
Pulmonary insufficiency                    Renal failure
Respiratory failure                        Schizophrenia
Shock – septic/cardiogenic                 Septicemia
Skin abscess                               Status – renal dialysis
Thrombocytopenia                           Urinary obstruction/retention
UTI                                        Ventricular fibrillation/tachycardia
Vitamin K deficiency




                                             3
                Important Physician Documentation
                   Impacting Severity Leveling.

     A complete patient history including chronic conditions
          impacting the patient's health care status:
    Status post organ transplant
    Post operative status
    Status post amputation
    History of malignancy
    Family history of cardiovascular disease, diabetes, hypertension, stroke
    All "ostomy statuses" should be documented
    Infectious disease status (hepatitis, TB, HIV)
    Antibiotic resistant organisms (MRSA, VRE, Acinetobacter)

               Patient's habits and/or social situation:
    Homelessness
    Non-compliance with meds
    Long-term use of drugs, for example: anticoagulants
    Exposure to toxins, for example: asbestos
    Obesity and morbid obesity
    Sleep apnea
    Drug and alcohol use
    Smoking history
    Unemployment
    Nutritional status
    Legal status (imprisonment, litigation, legal investigations, prosecution)
    Placement – unavailability of medical facilities

Treatments and procedures including ones not performed in the
              operating room or surgery suite:

    Hemodialysis
    Temporary pacer insertion
    PEG
    Other Gastrostomy
    Enterostomy
    Peritoneal Dialysis
    Subconvulsive ECT
    Video EEG
    Intubation
    Enteral infusion/tube feeds
    Mechanical ventilation
    Transfusion of any / all blood products
    Therapeutic plasmapheresis
    Therapeutic leukopheresis
    Therapeutic plateletpheresis



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Source: Colleen Garry, RN, BS, Clinical Documentation Manager, Medical University of South Carolina,
Charleston, SC. Reprinted with permission.

								
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