For The Critters Present
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1 For The Critters Present Be sure to Sepsis Sepsis secondary to UTI Bacteremia SIRS secondary to infection For More Info-Contact Your Documentation Specialist Pat Spadaro, R.N Rosanne Garofano, R.N Shawna Bianco, R.N. 3119
2 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 Rosanne Garofano, R.N Shawna Bianco, R.N. 3119
3 For Blood Pressure Issues Be sure to Essential hypertension Malignant hypertension Accelerated hypertension Secondary hypertension For More Info-Contact Your Documentation Specialist Pat Spadaro, R.N Rosanne Garofano, R.N Shawna Bianco, R.N. 3119
4 Be sure to... Is it... Acute Renal Failure? Acute Kidney Injury? Acute on Chronic Renal Failure? Acute Renal Failure 2 Acute Tubular Necrosis For more information, page your Documentation Specialist: Pat Spadaro,R.N Rosanne Garofano, R.N Shawna Bianco, R.N. 3119
5 Be sure to... IS IT: ACUTE? CHRONIC? ACUTE ON CHRONIC? SYSTOLIC? DIASTOLIC? For more information, page your Documentation Specialist: Pat Spadaro,R.N Rosanne Garofano, R.N Shawna Bianco, R.N. 3119
6 STAGE YOUR CKD Be sure to CKD Stage 1 GRF > 90 CKD Stage 2 GRF > CKD Stage 3 GRF > CKD Stage 4 GFR > CKD Stage 5/ESRD GFR < 15 For More Info-Contact Your Documentation Specialist Pat Spadaro, R.N Rosanne Garofano, R.N Shawna Bianco, R.N. 3119
7 FOR UNSTEADY GAIT OR BALANCE ISSUES Be sure to 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 Rosanne Garofano, R.N Shawna Bianco, R.N. 3119
8 Be sure to... For more information, page your Documentation Specialist: Pat Spadaro, R.N Rosanne Garofano, R.N Shawna Bianco, R.N. 3119
9 Be sure to... Is it: Angina? Acute Demand Ischemia? Acute Myocardial Infarction? For more information, page your Documentation Specialist: Pat Spadaro,R.N Rosanne Garofano, R.N Shawna Bianco, R.N. 3119
10 Diagnosis requires evaluation, monitoring or treatment of condition Neurology Documentation Improvement Tips No CC/MCC CC MCC HCT, H/H Acute blood loss anemia NA Hyponatremia Angina or CAD or demand ischemia New onset/accelerated/unstable/rest angina NSTEMI Aspiration Aspiration pneumonitis/pna Asthma Acute asthma/asthma exacerbation Acute respiratory failure Atelectasis on CXR report Atelectasis Change in MS Acute delirium Encephalopathy (i.e. 2 HTN, metabolic, toxic) CHF Chronic systolic/diastolic CHF Acute systolic/diastolic CHF Cocaine abuse (or any drug) Active cocaine abuse or dependence COPD on home 02 Chronic respiratory Failure Acute on chronic resp. failure COPD/bronchitis Acute COPD/COPD exacerbation Acute respiratory failure Cystitis 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 edema GERD/esophagitis Acute esophagitis Hypertensive 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 failure Overweight/obese Morbid obesity (if BMI > 40) Pleural effusion on CXR report Pleural effusion Renal insufficiency ARF or AKI ARF 2 ATN Respiratory 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 Vfib TIA Acute CVA Underweight/thin/frail Malnutrition/cachexia Severe malnutrition Unresponsive, obtunded Coma or cerebral edema Urosepsis Sepsis 2 UTI Weakness of extremity Acute hemiparesis Hemiparesis as late effect of stroke Quadriplegia Alice Greene, MD- Medical Director of Care Management
11 Surgery Documentation Improvement Tips Diagnosis requires evaluation, monitoring or treatment of condition No CC/MCC CC MCC Angina, CAD or chest pain New onset/accelerated/unstable/rest angina NSTEMI Air-fluid levels Ileus Small bowel obstruction Ascites on CT/US Ascites Peritonitis Aspiration Aspiration pneumonitis/pna Asthma Acute asthma/asthma exacerbation Atelectasis on CXR Atelectasis Change in MS Acute delirium Encephalopathy (i.e. metabolic, toxic) CHF Chronic systolic/diastolic CHF Acute systolic/diastolic CHF Cocaine abuse Active cocaine dependence COPD/bronchitis Acute COPD/COPD exacerbation Acute respiratory failure Cystitis UTI or bacteremia Sepsis or SIRS 2 UTI HCT, drop H/H Acute blood loss anemia NA, K Hyponatremia, Hypokalemia Amylase/lipase Chronic pancreatitis Acute pancreatitis Demand ischemia New onset/accelerated/unstable/rest angina NSTEMI Diabetes poorly controlled Uncontrolled (Not CC but impacts SOI) Diabetic ketoacidosis Diverticulosis Diverticulitis GI bleed 2 diverticulosis/diverticulitis Fluid overload Acute pulmonary edema Gastritis Acute gastric ulcer GI bleed 2 gastric ulcer GERD/esophagitis Acute esophagitis GI bleed 2 esophageal ulcer Hypertensive urgency/crisis Accelerated or malignant HTN Acute systolic/diastolic CHF Hypotension Shock (i.e. cardiogenic, hypovolemic) Hypoxemia/Hypoxia Acute respiratory failure Lung infiltrate/cough Pneumonia End stage lung dz/on home 02 Chronic respiratory failure Acute on chronic resp. failure Overweight/obese Morbid obesity ( if BMI > 40) Pericardial effusion on echo Pericardial effusion Acute diastolic CHF due to tamponade Pleural effusion on CXR Pleural effusion Empyema Renal insufficiency ARF or AKI ARF 2 ATN Respiratory insufficiency/distress Acute respiratory failure/ards Stool occult blood/guaic pos. GI bleeding GI bleed from defined site (i.e. PUD) Tachycardia PSVT/atrial flutter/pat/vtach Vfib Troponin leak/demand ischemia New onset/accelerated/unstable/rest angina NSTEMI Underweight/thin/frail Malnutrition/cachexia Severe malnutrition Unresponsive, obtunded Coma Urosepsis Sepsis 2 UTI Alice Greene, MD- Medical Director of Care Management
12 Medicine Documentation Improvement Tips Diagnosis requires evaluation, monitoring or treatment of condition No CC/MCC CC MCC Angina or CAD New onset/accelerated/unstable/rest angina NSTEMI Aspiration Aspiration pneumonitis/pna Asthma Acute asthma/asthma exacerbation Acute respiratory failure Atelectasis on CXR report Atelectasis Change in MS Acute delirium Encephalopathy (i.e. 2 HTN, metabolic, toxic) CHF Chronic systolic/diastolic CHF Acute systolic/diastolic CHF Cocaine abuse (or any drug) Active cocaine abuse or dependence COPD/bronchitis Acute COPD/COPD exacerbation Acute respiratory failure COPD on home 02 Chronic respiratory failure Acute on chronic resp. failure Cystitis UTI/UTI with bacteremia Sepsis or SIRS 2 UTI (NOT Urosepsis) HCT, drop H/H NA Dementia Diabetes poorly controlled Acute blood loss anemia Hyponatremia Dementia specified (i.e. vascular, Alzheimer s) Uncontrolled (Not CC but impacts SOI) Fluid overload Pulmonary edema GERD/esophagitis Acute esophagitis Hypertensive heart disease Hypertensive cardiomyopathy Acute systolic/diastolic CHF Hypertensive 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 failure Lung infiltrate/cough Pneumonia Overweight/obese Morbid obesity (if BMI > 40) Pericardial effusion on echo report Pericarditis or Pericardial effusion Acute diastolic CHF Pleural effusion on CXR report Pleural effusion Empyema Renal insufficiency ARF or AKI ARF 2 ATN Respiratory insufficiency/distress Acute respiratory failure Seizure or Seizure DO Intractable/poorly controlled 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 Vfib Troponin leak or demand ischemia New onset/accelerated/unstable/rest angina NSTEMI Underweight/thin/frail Malnutrition/cachexia Severe malnutrition Unresponsive, obtunded Urosepsis Coma or cerebral edema Sepsis 2 UTI Alice Greene, MD- Medical Director of Care Management
13 Cardiac Documentation Improvement Tips Diagnosis requires evaluation, monitoring or treatment of condition No CC/MCC CC MCC Angina or CAD New onset/accelerated/unstable/rest angina NSTEMI Aspiration Aspiration pneumonitis/pna Asthma Acute asthma/asthma exacerbation Atelectasis on CXR Atelectasis Change in MS Acute delirium Encephalopathy (i.e. 2 HTN) CHF Chronic systolic/diastolic CHF Acute systolic/diastolic CHF Cocaine abuse Active cocaine dependence COPD/bronchitis Acute COPD/COPD exacerbation Acute respiratory failure Cor pulmonale Acute cor pulmonale Cystitis UTI or bacteremia Sepsis or SIRS 2 UTI HCT, drop H/H Acute blood loss anemia NA Hyponatremia Demand ischemia New onset/accelerated/unstable/rest angina NSTEMI Diabetes poorly controlled Uncontrolled (Not CC but impacts SOI) Fluid overload Pulmonary edema GERD/esophagitis Acute esophagitis Hypertensive heart disease Hypertensive cardiomyopathy Acute systolic/diastolic CHF Hypertensive urgency/crisis Accelerated or malignant HTN Acute systolic/diastolic CHF Hypotension Shock (i.e. cardiogenic) Hypoxemia/Hypoxia Acute respiratory failure Lung infiltrate/cough Pneumonia End stage lung dz/on home 02 Chronic respiratory failure Acute on chronic resp. failure Overweight/obese Morbid obesity ( if BMI > 40) Pericardial effusion on echo Pericardial effusion Acute pericarditis Pleural effusion on CXR Pleural effusion Empyema Renal insufficiency ARF or AKI ARF 2 ATN Respiratory insufficiency/distress Acute respiratory failure Stool occult blood/guaic pos. GI bleeding GI bleed from defined site (i.e. PUD) Tachycardia PSVT/atrial flutter/pat/vtach Vfib Troponin leak New onset/accelerated/unstable/rest angina NSTEMI Underweight/thin/frail Malnutrition/cachexia Severe malnutrition Unresponsive, obtunded Coma Urosepsis Sepsis 2 UTI Alice Greene, MD- Medical Director of Care Management
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