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Download Clinical documentation gold standards card Severity / Co
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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 Alcohol intoxication/withdrawal/abuse Angina pectoris Aorta aneurysm-rupture Asthma – acute exacerbation Atelectasis Bacteremia Boils Bronchiectasis Cachexia Cardiomyopathy CHF Cirrhosis COPD Coronary ischemia CVA with cerebral infarction Decubitus ulcer Diabetes, "uncontrolled" Electrolyte imbalance Encephalopathy – anoxic Fecal Impaction Addison's disease Anemia- blood loss/aplastic Anorexia nervosa Ascites Asthma – status asthmaticus Atrial fibrillation/atrial flutter Bleeding esophageal varicies Brachial neuritis Bronchitis Cardiac arrest Cellulitis Cholangitis Convulsions Cor pulmonale, acute Cystitis Dehydration Diabetes, type 1 or II Drug dependence Emphysema Endometritis Fluid retention 2 Severity / Co-morbidities Secondary Diagnoses Impacting DRG Assignment (This is not a complete list of co-morbidities) GI hemorrhage Heart block –AV/BBB/trifascicular Hematuria Hemorrhage, cerebral, non-traumatic Hydronephrosis Hypertensive heart disease w/CHF Infected hydrocele Leukopenia Melena MVP Myocarditis, acute Orchitis with abscess Pancytopenia Paroxysmal tachycardia Pericarditis, acute Phlebitis Pneumonia Prostatitis, acute Pulmonary insufficiency Respiratory failure Shock – septic/cardiogenic Skin abscess Thrombocytopenia UTI Vitamin K deficiency Hallucinations Hematemesis Hemoptysis Hepatitis Hypernatremia/Hyponatremia Hypoxia Infective myositis Malnutrition MI, acute (less than 8 weeks) Mitral Regurgitation Neutropenia Pancreatitis, acute Paralytic ileus Pathological fracture Peritonitis Pleural effusion Pneumothorax Pulmonary embolism Renal failure Schizophrenia Septicemia Status – renal dialysis Urinary obstruction/retention Ventricular fibrillation/tachycardia 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.
