Documentation Clarification Request

(Not part of the medical record)

Purpose: to clarify provider documentation whenever there is conflicting, ambiguous, or incomplete information in the medical record regarding any significant reportable condition or procedure.

Reportable conditions: defined by Official Coding Guidelines as affecting patient care by requiring:

Clinical Evaluation Extended length of hospital stay

Therapeutic treatment Increased nursing care and/or monitoring

Diagnostic Procedures

Clinically significant conditions: those listed above as well as those conditions that have implications for future health care needs. Use of a qualifier such as possible, probable, unable to rule out is acceptable in the inpatient discharge summary for cases requiring further work-up after discharge.

Chart review indicates needed clarification based on the Official Coding Guidelines.

Rationale: Specificity is required to code each component of the sepsis continuum. Cause/effect relationship must be stated, particularly with involvement of a device/graft/implant; e.g. sepsis due to Foley catheter or to vascular access, etc.

Criteria for Sepsis*

Sepsis: Presence of 1 or more criteria in this row. / Positive cultures (but not required) or WBCs present in otherwise sterile fluid: blood, urine, sputum, CSF, etc.? / Prescribed anti-infective therapy: antibiotic, antifungal, and other? / Documentation of pneumonia: positive x-ray or clinical presentation? / Perforated viscus: perforation of a hollow organ, e.g. bowel?
SIRS: Presence of 2 criteria in this row / Temperature:
100.4° F. or
96.8° F. / Heart rate:
90 bpm / Respiratory rate:
20/min. / WBC count:
12,000/mm2
4,000/mm2
> 10% bands
MODS: Presence of 1 organ system dysfunction / Cardiac:
1. SBP 90
2. MAP 70
Renal:
1. urine out < 0.5 ml/kg/hr
Any of the above for > 1 hr despite adequate fluid resuscitation, or requires vasopressor support / Respiratory:
1. PaO2/FiO2 ratio 250
2. PEEP > 7.5
3. mech. ventilation
Metabolic:
1. low pH with high lactate (7.3 with lactate > upper limits of normal) / Hematologic:
Platelets < 100,000 or PT/PTT > upper limit of normal
Hepatic:
Liver enzymes > 2X upper limit of normal / CNS:
Altered level of consciousness or a reduced Glasgow Coma score
*Source: Bone, RC; Balk, RA; Cerra, FB, et al. Critical Care Medicine. 1992; 20:864-874.

Check 1 of these 5 response options so we may know where to find yourresponse.

If this is a retro-query post-discharge, send written response &fax form to HI 375-3485.

Dictated a note/addendum ( use Work Type=15) Documented on a progress note(send w/ this fax)

No further documentation is indicated Not a reportable condition  Other diagnosis noted

Sandy Beatty, CDS
pager 375-2642 /  Cindy Lemmon, CDS
pager 375-6699 /  Cindy Spann, Director of HI
ext. 376-5011