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Congestive Heart Failure Clinical Documentation Query Dear Dr._______________ date: A non-specific diagnosis of _______________________has been documented for your patient. By referencing the chart on the back of this sheet, please clarify in your progress note and discharge summary the nature and acuity of CHF. Clinical Manifestations Echo Report BNP Results Medications Diuresis Results Could you please clarify if you are treating any of the following conditions? (1) (2) (3) If you disagree please document here._______________________________ Ibett Aponte RN #350 Lynn Manalo, RN #554 Patty Spry, RN #572 Clinical Documentation Team Please document in the progress notes. This query is not a permanent part of the medical record and not intended to take the place of your independent medical judgment Emerson Hospital CDI Program (1) Acute – First event (2) Acute on Chronic – Subsequent events (3) Chronic – Is maintained on any combination of meds: Digoxin, Diuretics, Ace Inhibitors, Angiotensin II Receptor Blockers, Calcium Channel Blockers, Nitrates, &/or Beta Blockers. Diastolic Heart Failure ● Evidence of diastolic dysfunction on echo ● Evidence of normal systolic function with an EF>50% during a heart failure event (sometimes called right sided heart failure) ●Concentric left ventricular hypertrophy & abnormal diastolic filling Systolic Heart Failure ●Evidence of reduced extent of contraction during systole resulting in systolic dysfunction ●EF<40-50% (sometimes called left sided heart failure) ●Left ventricular dilation & Low cardiac output