I have a question regarding some of the additions to the spec manual for July.
Under Severe Sepsis, in the examples of acceptable/unacceptable documentation,
there are a couple examples I'm questioning.
Examples of Acceptable physician/APN/PA documentation: o "Creatinine
3.0, CKD, HD in am" Do not use value since the creatinine and the chronic
condition are in the same sentence in the documentation.
We wouldn't use this anyway, correct, because of the HD? Elsewhere it states:
Creatinine >2.0 o If there is physician/APN/PA documentation the patient has
end stage renal disease (ESRD) and is on hemodialysis or peritoneal dialysis
all reported creatinine levels should be disregarded as signs of organ
dysfunction. ESRD (on hemodialysis or peritoneal dialysis) and creatinine
levels or reference to elevated creatinine levels do not need to be included in
the same physician/APN/PA documentation.
Under Unacceptable documentation it states:
[cid:[email protected]]
However, we wouldn't use the INR because of the documentation of being on
Warfarin, correct?
Because elsewhere there's a bullet that states:
If the suggested data source shows the patient was given an anticoagulant
medication in Appendix C Table 5.3, an elevated INR or aPTT level should not be
used as organ dysfunction. Physician/APN/PA documentation is not required.
Thanks,
Karen Belfi, RN, MSN
Quality Outcomes Coordinator
Lankenau Medical Center
(484)476-8092
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