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Transcript
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