when I find an example of really good documentation, I award the Golden Pen to that nurse, and praise him/her publicly. What a great idea We have been looking for something like that. -----Original Message----- From: Holly Sox, RN, RAC-C [mailto:[EMAIL PROTECTED] Sent: Tuesday, November 25, 2003 7:57 AM To: [EMAIL PROTECTED] Subject: Re: sentinel event question . answer needed. 2 nd attempt
Sorry, Nancy, for not replying sooner. I would not code impaction based on a nurse's note, just as I would not code a UTI or pneumonia simply based on a nurse's note. In this case, I would write a progress note (we keep MDS/Care plan progress notes with the care plan, but you could do a nurse's note if that's your facility policy) stating that a nurse's note indicated impaction, but that the KUB did not support that assessment, and that the constipation was relieved by oral mag citrate. Then, do an inservice with your nurses on what is required for the diagnosis of impaction. I don't have the reference with me for this, but we teach that impaction is hard stool identified on Xray or digital exam that must be manually removed. If the patient/resident can clear the rectum with oral laxatives , suppository or enema then it is not an impaction. See my PPS Alert article this month about documentation. I have tried using an incentive approach.. when I find an example of really good documentation, I award the Golden Pen to that nurse, and praise him/her publicly. Holly ----- Original Message ----- From: [EMAIL PROTECTED] <mailto:[EMAIL PROTECTED]> To: [EMAIL PROTECTED] <mailto:[EMAIL PROTECTED]> Sent: Monday, November 24, 2003 5:37 PM Subject: sentinel event question . answer needed. 2 nd attempt HI I have a resident admitted approc 11 days ago. She had a KUB done to confirm a right utereral stent placement. Unfortunaley, the results read " severe constipation with dilatation of the colon and copious stool in the rectum" Also, unfortunaely , a nurse wrote in her nrsg notes fecal impaction per KUB results new order rec'd for mag citrate. THis resident's adm obra assessment is due and this ? fecal impaction falls with in the 14 day window. What would your code fecal impaction or not? please help THANKS NANCY /---------------------------------------------------------- The Case Mix Discussion Group is a free service of the American Association of Nurse Assessment Coordinators "Committed to the Assessment Professional" Be sure to visit the AANAC website. Accurate answers to your questions posted to NAC News and FAQs. For more info visit us at http://www.aanac.org -----------------------------------------------------------/
