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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. 1 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 2 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 4 Source: Colleen Garry, RN, BS, Clinical Documentation Manager, Medical University of South Carolina, Charleston, SC. Reprinted with permission.
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