Most states allow 30 days post discharge for clinicians to amend documentation. We abstract retrospectively, but usually within that 30 days. So we query and have docs update their documentation. It's also good education for the clinicians.
Stephanie Wilson, BSN Jordan Valley Medical Center Quality Management/Quality Reviewer 3870 West 9000 South West Jordan, Utah 84088 Office 801.561.8888 xt. 4526 Cell 801.580.8320 [email protected] CONFIDENTIAL COMMUNICATION/RISK MANAGEMENT PRIVILEGE/QUALITY MANAGEMENT PRIVILEGE/MAY CONTAIN CONFIDENTIAL PATIENT SAFETY WORK PRODUCT INFORMATION WHICH IS PROTECTED UNDER FEDERAL PATIENT SAFETY ACT/IN FLORIDA INFORMATION MAY BE SUBJECT TO SUBMISSION INTO PSES FOR PURPOSE OF REPORTING TO PSO. DO NOT REMOVE OR DISCLOSE UNLESS AUTHORIZED BY RISK DIRECTOR AND/OR QUALITY MANAGEMENT DEPARTMENT. From: "Belfi, Karen" <[email protected]> To: Greg Stanford <[email protected]>, Dena Videtic <[email protected]> Cc: "Murray, Sandra" <[email protected]>, "[email protected]" <[email protected]> Date: 07/08/2016 02:15 PM Subject: Re: [Sepsis Groups] [EXTERNAL] Re: Sepsis Question on organ dysfunction Sent by: "Sepsisgroups" <[email protected]> If we are reviewing concurrently that would be helpful. However, if we are retroactively abstracting a chart, we can only go by documentation in the chart. The specification manual is clear that if there is no documentation the organ dysfunction isn?t documented as related to a different condition, we are to use it as organ dysfunction criterion. It may not always make sense clinically, but we need to follow the guidelines. Karen Belfi, RN, MSN Quality Outcomes Coordinator Lankenau Medical Center 484-476-8092 Pager: 5240 From: Sepsisgroups [mailto:[email protected]] On Behalf Of Greg Stanford Sent: Wednesday, July 06, 2016 9:40 PM To: Dena Videtic Cc: Murray, Sandra; [email protected] Subject: [EXTERNAL] Re: [Sepsis Groups] Sepsis Question on organ dysfunction I agree with Dena. Cholecystitis doesn?t generally give you a bili that high, and I would think of obstruction and cholangitis. Without that, sepsis would be next on my list. but I would query the doctor to better understand his/her clinical impression. Greg Stanford, MD Medical Director Clinical Documentation Improvement and Outcomes 1840 Amherst Street | Winchester, Va 22601 Phone: (540) 596 4999 Cell: 540 664 5736 | |gstanfor @valleyhealthlink.com CONFIDENTIALITY NOTICE: This e-mail is confidential, may be legally privileged, and for the intended recipient only. Access, disclosure, copying, forwarding and distribution by any means is strictly prohibited. If received in error, do not read but delete and e-mail confirmation to the sender. On Jul 5, 2016, at 8:12 AM, Dena Videtic <[email protected]> wrote: Sandra, This is a good question. From an abstraction point of view, I would look for physician documentation that the patient has Severe Sepsis because as nurses, it is not in our scope of practice to diagnose patients. The bilirubin could be elevated due to a biliary obstruction. An interesting article was published in April about the subjectivity of sepsis diagnosis even among physicians. If you?re interested it is called: ?Diagnosing Sepsis is Subjective and Highly Variable: A Survey of Intensivists Using Case Vignettes? http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4822273/ Dena Videtic RN BSN Quality Indicators Doctors Hospital Coral Gables, FL 786-308-3315 From: Sepsisgroups [mailto:[email protected]] On Behalf Of Murray, Sandra Sent: Thursday, June 30, 2016 2:26 PM To: [email protected] Subject: [Sepsis Groups] Sepsis Question on organ dysfunction Would you count a t.bili of 9.3 as organ dysfunction if patient comes in with abdominal pain, meets the SIRS criteria and the CT shows pt to have acute cholecystitis? 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