Download 244606

Documentation Clarification Request
(Not part of the medical record)
Purpose: to clarify provider documentation whenever there is conflicting, ambiguous, or incomplete information in
the medical record regarding any significant reportable condition or procedure.
Reportable conditions: defined by Official Coding Guidelines as affecting patient care by requiring:
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 Extended length of hospital stay
 Increased nursing care and/or monitoring
Clinical Evaluation
Therapeutic treatment
Diagnostic Procedures
Clinically significant conditions: those listed above as well as those conditions that have implications for
future health care needs. Use of a qualifier such as possible, probable, unable to rule out is acceptable in the
inpatient discharge summary for cases requiring further work-up after discharge.
Chart review indicates needed clarification based on the Official Coding Guidelines.
Cardiogenic Shock
Defined as:
 a sustained (>30 minutes) episode of systolic blood pressure <90 mm Hg, and/or
 a cardiac index <2.2 L/min/m2 determined to be secondary to cardiac dysfunction, and/or
 the requirement for parenteral inotropic or vasopressor agents or mechanical support to
maintain blood pressure and cardiac index above these specified levels (e.g., intra aortic
balloon pump (IABP), extracorporeal circulation, ventricular assist devices).
 hemodynamic compromise (with or without extraordinary supportive therapy) must persist for
at least 30 minutes.
Exclusions:
 Transient episodes of hypotension reversed with IV fluid or atropine
Source: Acute Coronary Syndromes Data Standards (JACC 2001 38: 2114 -30)
Check 1 of these 5 response options so we may know where to find your response.
If this is a retro-query post-discharge, send written response & fax form to HI 375-3485.
 Dictated a note/addendum (use Work Type=15)
 No further documentation is indicated
 Sandy Beatty, CDS
pager 375-2642
 Documented on a progress note (send w/ this fax)
 Not a reportable condition
 Cindy Lemmon, CDS
pager 375-6699
 Other diagnosis noted
 Cindy Spann, Director of HI
ext. 376-5011