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For The Critters Present
Be sure to…
DOCUMENT!!! Sepsis Sepsis secondary to UTI Bacteremia SIRS secondary to infection
For More Info-Contact Your Documentation Specialist
Pat Spadaro, R.N. 6796 Rosanne Garofano, R.N. 6089 Shawna Bianco, R.N. 3119
For Brain Pain…
Be sure to Document!!! Cerebral edema secondary to stroke Vasogenic edema Cerebral edema secondary to brain tumor Cerebral edema secondary to infection Brain compression
For More Info-Contact Your Documentation Specialist Pat Spadaro, R.N. 6796 Rosanne Garofano, R.N. 6089 Shawna Bianco, R.N. 3119
For Blood Pressure Issues
Be sure to…
DOCUMENT!!! Essential hypertension Malignant hypertension Accelerated hypertension Secondary hypertension
For More Info-Contact Your Documentation Specialist
Pat Spadaro, R.N. 6796 Rosanne Garofano, R.N. 6089 Shawna Bianco, R.N. 3119
For more information, page your Documentation Specialist: Pat Spadaro,R.N. 6796 Rosanne Garofano, R.N. 6089 Shawna Bianco, R.N. 3119
Be sure to...
DOCUMENT!!!
Acute Renal Failure? Acute Kidney Injury? Acute on Chronic Renal Failure? Acute Renal Failure 2° Acute Tubular Necrosis
Is it ...
ACUTE?
CHRONIC?
ACUTE ON CHRONIC?
SYSTOLIC?
DIASTOLIC?
IS IT:
Be sure to... DOCUMENT!!!DOCUMENT!!!DOCUMENT!!!
For more information, page your Documentation Specialist:
Pat Spadaro,R.N. 6796 Rosanne Garofano, R.N. 6089 Shawna Bianco, R.N. 3119
STAGE YOUR CKD
Be sure to…
DOCUMENT!!! CKD Stage 1 GRF > 90 CKD Stage 2 GRF > 60-89 CKD Stage 3 GRF > 30-59 CKD Stage 4 GFR > 15-29 CKD Stage 5/ESRD GFR < 15
For More Info-Contact Your Documentation Specialist Pat Spadaro, R.N. 6796 Rosanne Garofano, R.N. 6089 Shawna Bianco, R.N. 3119
FOR UNSTEADY GAIT OR BALANCE ISSUES
Be sure to…
DOCUMENT!!! CEREBELLAR ATAXIA FREDERICK ATAXIA VESTIBULAR DYSFUNCTION SECONDARY PARKINSONISM NORMAL PRESSURE HYDROCEPHALUS BENIGN POSTURAL VERTIGO
For More Info-Contact Your Documentation Specialist
Pat Spadaro, R.N. 6796 Rosanne Garofano, R.N. 6089 Shawna Bianco, R.N. 3119
For more information, page your Documentation Specialist:For more information, page your Documentation Specialist:For more information, page your Documentation Specialist:
Pat Spadaro, R.N. 6796 Pat Spadaro, R.N. 6796 Pat Spadaro, R.N. 6796 Rosanne Garofano, R.N. 6089 Rosanne Garofano, R.N. 6089 Rosanne Garofano, R.N. 6089 Shawna Bianco, R.N. 3119Shawna Bianco, R.N. 3119Shawna Bianco, R.N. 3119
Be sure to...
DOCUMENT!!!
For more information, page your Documentation Specialist: Pat Spadaro,R.N. 6796 Rosanne Garofano, R.N. 6089 Shawna Bianco, R.N. 3119
Be sure to...
DOCUMENT!!!
Is it:
• Angina?
• Acute Demand Ischemia?
• Acute Myocardial Infarction?
No CC/MCC CC MCC↓HCT, ↓ H/H Acute blood loss anemia↓ NA HyponatremiaAngina or CAD or demand ischemia New onset/accelerated/unstable/rest angina NSTEMIAspiration Aspiration pneumonitis/PNAAsthma Acute asthma/asthma exacerbation Acute respiratory failureAtelectasis on CXR report AtelectasisChange in MS Acute delirium Encephalopathy (i.e. 2° HTN, metabolic, toxic)CHF Chronic systolic/diastolic CHF Acute systolic/diastolic CHFCocaine abuse (or any drug) Active cocaine abuse or dependenceCOPD on home 02 Chronic respiratory Failure Acute on chronic resp. failureCOPD/bronchitis Acute COPD/COPD exacerbation Acute respiratory failureCystitis UTI/UTI with bacteremia Sepsis or SIRS 2° UTI (NOT Urosepsis)Dementia Dementia specified (i.e. vascular, Alzheimer’s, Parkinson’s)Diabetes poorly controlled Uncontrolled (Not CC but impacts SOI)Fluid overload Pulmonary edemaGERD/esophagitis Acute esophagitisHypertensive urgency/crisis Accelerated or malignant HTN Acute systolic/diastolic CHF
Hypotension Shock NOS Shock specified (i.e. cardiogenic, septic, hypovolemic)
Hypoxemia/Hypoxia Chronic respiratory failure Acute respiratory failureOverweight/obese Morbid obesity (if BMI > 40) Pleural effusion on CXR report Pleural effusionRenal insufficiency ARF or AKI ARF 2° ATNRespiratory insufficiency/distress Acute respiratory failure
Seizure or seizure DO Intractable, poorly controlled, refractory, or treatment resistant seizure disorder Status epilepticus
Stool occult blood/guaic pos. GI bleeding GI bleed from defined site (i.e. PUD)Tachycardia PSVT/atrial flutter/PAT/Vtach VfibTIA Acute CVAUnderweight/thin/frail Malnutrition/cachexia Severe malnutritionUnresponsive, obtunded Coma or cerebral edemaUrosepsis Sepsis 2° UTIWeakness of extremity Acute hemiparesis Hemiparesis as late effect of stroke Quadriplegia
Alice Greene, MD- Medical Director of Care Management
Neurology Documentation Improvement TipsDiagnosis requires evaluation, monitoring or treatment of condition
No CC/MCC CC MCCAngina, CAD or chest pain New onset/accelerated/unstable/rest angina NSTEMIAir-fluid levels Ileus Small bowel obstructionAscites on CT/US Ascites PeritonitisAspiration Aspiration pneumonitis/PNAAsthma Acute asthma/asthma exacerbationAtelectasis on CXR AtelectasisChange in MS Acute delirium Encephalopathy (i.e. metabolic, toxic)CHF Chronic systolic/diastolic CHF Acute systolic/diastolic CHFCocaine abuse Active cocaine dependenceCOPD/bronchitis Acute COPD/COPD exacerbation Acute respiratory failureCystitis UTI or bacteremia Sepsis or SIRS 2° UTI HCT, drop H/H Acute blood loss anemia NA, K Hyponatremia, HypokalemiaAmylase/lipase Chronic pancreatitis Acute pancreatitisDemand ischemia New onset/accelerated/unstable/rest angina NSTEMIDiabetes poorly controlled Uncontrolled (Not CC but impacts SOI) Diabetic ketoacidosisDiverticulosis Diverticulitis GI bleed 2˚ diverticulosis/diverticulitisFluid overload Acute pulmonary edemaGastritis Acute gastric ulcer GI bleed 2˚ gastric ulcerGERD/esophagitis Acute esophagitis GI bleed 2˚ esophageal ulcerHypertensive urgency/crisis Accelerated or malignant HTN Acute systolic/diastolic CHFHypotension Shock (i.e. cardiogenic, hypovolemic)Hypoxemia/Hypoxia Acute respiratory failureLung infiltrate/cough PneumoniaEnd stage lung dz/on home 02 Chronic respiratory failure Acute on chronic resp. failureOverweight/obese Morbid obesity ( if BMI > 40)Pericardial effusion on echo Pericardial effusion Acute diastolic CHF due to tamponadePleural effusion on CXR Pleural effusion EmpyemaRenal insufficiency ARF or AKI ARF 2° ATNRespiratory insufficiency/distress Acute respiratory failure/ARDSStool occult blood/guaic pos. GI bleeding GI bleed from defined site (i.e. PUD)Tachycardia PSVT/atrial flutter/PAT/Vtach VfibTroponin leak/demand ischemia New onset/accelerated/unstable/rest angina NSTEMIUnderweight/thin/frail Malnutrition/cachexia Severe malnutritionUnresponsive, obtunded ComaUrosepsis Sepsis 2° UTI
Surgery Documentation Improvement TipsDiagnosis requires evaluation, monitoring or treatment of condition
Alice Greene, MD- Medical Director of Care Management 4-3768
No CC/MCC CC MCCAngina or CAD New onset/accelerated/unstable/rest angina NSTEMIAspiration Aspiration pneumonitis/PNAAsthma Acute asthma/asthma exacerbation Acute respiratory failureAtelectasis on CXR report AtelectasisChange in MS Acute delirium Encephalopathy (i.e. 2° HTN, metabolic, toxic)CHF Chronic systolic/diastolic CHF Acute systolic/diastolic CHFCocaine abuse (or any drug) Active cocaine abuse or dependenceCOPD/bronchitis Acute COPD/COPD exacerbation Acute respiratory failureCOPD on home 02 Chronic respiratory failure Acute on chronic resp. failureCystitis UTI/UTI with bacteremia Sepsis or SIRS 2° UTI (NOT Urosepsis) HCT, drop H/H Acute blood loss anemia NA HyponatremiaDementia Dementia specified (i.e. vascular, Alzheimer’s)Diabetes poorly controlled Uncontrolled (Not CC but impacts SOI)Fluid overload Pulmonary edemaGERD/esophagitis Acute esophagitisHypertensive heart disease Hypertensive cardiomyopathy Acute systolic/diastolic CHFHypertensive urgency/crisis Accelerated or malignant HTN Acute systolic/diastolic CHFHypotension Shock NOS Shock specified (i.e. cardiogenic, septic, hypovolemic)Hypoxemia/Hypoxia Chronic respiratory failure Acute respiratory failureLung infiltrate/cough PneumoniaOverweight/obese Morbid obesity (if BMI > 40)Pericardial effusion on echo report Pericarditis or Pericardial effusion Acute diastolic CHFPleural effusion on CXR report Pleural effusion EmpyemaRenal insufficiency ARF or AKI ARF 2° ATNRespiratory insufficiency/distress Acute respiratory failureSeizure or Seizure DO Intractable/poorly controlled seizure disorder Status epilepticusStool occult blood/guaic pos. GI bleeding GI bleed from defined site (i.e. PUD)Tachycardia PSVT/atrial flutter/PAT/Vtach VfibTroponin leak or demand ischemia New onset/accelerated/unstable/rest angina NSTEMIUnderweight/thin/frail Malnutrition/cachexia Severe malnutritionUnresponsive, obtunded Coma or cerebral edemaUrosepsis Sepsis 2° UTI
Medicine Documentation Improvement TipsDiagnosis requires evaluation, monitoring or treatment of condition
Alice Greene, MD- Medical Director of Care Management
No CC/MCC CC MCCAngina or CAD New onset/accelerated/unstable/rest angina NSTEMIAspiration Aspiration pneumonitis/PNAAsthma Acute asthma/asthma exacerbationAtelectasis on CXR AtelectasisChange in MS Acute delirium Encephalopathy (i.e. 2° HTN)CHF Chronic systolic/diastolic CHF Acute systolic/diastolic CHFCocaine abuse Active cocaine dependenceCOPD/bronchitis Acute COPD/COPD exacerbation Acute respiratory failureCor pulmonale Acute cor pulmonaleCystitis UTI or bacteremia Sepsis or SIRS 2° UTI HCT, drop H/H Acute blood loss anemia NA HyponatremiaDemand ischemia New onset/accelerated/unstable/rest angina NSTEMIDiabetes poorly controlled Uncontrolled (Not CC but impacts SOI)Fluid overload Pulmonary edemaGERD/esophagitis Acute esophagitisHypertensive heart disease Hypertensive cardiomyopathy Acute systolic/diastolic CHFHypertensive urgency/crisis Accelerated or malignant HTN Acute systolic/diastolic CHFHypotension Shock (i.e. cardiogenic)Hypoxemia/Hypoxia Acute respiratory failureLung infiltrate/cough PneumoniaEnd stage lung dz/On home 02 Chronic respiratory failure Acute on chronic resp. failureOverweight/obese Morbid obesity ( if BMI > 40)Pericardial effusion on echo Pericardial effusion Acute pericarditisPleural effusion on CXR Pleural effusion EmpyemaRenal insufficiency ARF or AKI ARF 2° ATNRespiratory insufficiency/distress Acute respiratory failureStool occult blood/guaic pos. GI bleeding GI bleed from defined site (i.e. PUD)Tachycardia PSVT/atrial flutter/PAT/Vtach VfibTroponin leak New onset/accelerated/unstable/rest angina NSTEMIUnderweight/thin/frail Malnutrition/cachexia Severe malnutritionUnresponsive, obtunded ComaUrosepsis Sepsis 2° UTI
Cardiac Documentation Improvement TipsDiagnosis requires evaluation, monitoring or treatment of condition
Alice Greene, MD- Medical Director of Care Management 4.2011
