MHHS Documentation Question*

HIV Infection

Dear Doctor: For accurate reporting of all diagnoses and procedures and for accurate reflection of your patient’s severity of illness and risk of mortality, please clarify both in your progress notes and discharge summary the following. Remember, specifying the causative process of symptoms may support a higher level of E & M .

Concerning the following clinical indicators: Your documentation of “HIVpositive” in:

Patient is / is not on antiretroviral medications.

The CD4 count is reported to be:

The viral load is reported to be:

In addition, it is documented in that the patient has the following conditions:

______

Note: per the CDC” AIDS is the final stage of HIV infection. A person infected with HIV is diagnosed with AIDS when he or she has one or more opportunistic infections, such as pneumonia or tuberculosis, and/or has a dangerously low number of CD4+ T cells (less than 200 cells per cubic millimeter of blood).

Question(s) that apply to this case:

In your medical opinion, are any of this patient’s current or previous conditions associated with their HIV positive status? If so, could you please document such making sure to link the HIV status with the condition?

Is the current condition an asymptomatic HIV infection? (i.e. patient does not have and has never had an HIV related illness) If so, could you please document as such?

Is the patient HIV positive only or are there specific associated conditions that clinically support the diagnosis of HIV with AIDS? If so, could you please document such?

Common conditions associated with AIDS are:

Septicemia

Coccidiosis

Tuberculosis

Mycobacterial infections

Meningitis

Encephalitis

Herpes zoster

Herpetic infections that include genitalia

Candidal infection of mouth, skin, nails

Histoplasmosis

Toxoplasmosis

Pneumocystosis

Kaposi’s Sarcoma

Burkitt’s tumor or Lymphoma

Pneumoniasi.e.pneumococcal, strep, viral, SARS, avian influenza

Unable to Determine

Other/ Unknown

TO RESPOND, PLEASE SELECT ONE OF THE FOLLOWING AT THE BOTTOM OF THE SCREEN:

Add Document: to attach an electronic Progress Note to the Care4 record. This becomes a permanent part of the medical record.

Cannot Clarify: if you cannot provide any further diagnoses and/or specificity documentation.

Message Back to Requestor: if you want to send the Documentation Specialist an internal email (e.g. stating you have updated the paper medical record.)

You may also call the Clinical Documentation Specialist that generated this query at: 713-

Thank you for your clarification!

* Please Note: This query is not a permanent part of the medical record. Last Update: 4/17/12