Guest Post: Words to clarify by

by Sylvia Hoffman, RN

Many novice CDI specialists do not readily identify when a diagnosis needs clarification. The following list is intended to serve a gentle reminder to “dig deeper.” Here is a list of “clue” words to help you identify when a query may be needed for clarification or specificity.

AMS needs clarification as to possible Acute Confusional State, Alzheimer’s Dementia, or Alzheimer’s with Behavioral Disturbance. If with associated Infection, metabolic condition, etc. it could also indicate Encephalopathy.

Urosepsis could be UTI or Sepsis secondary to UTI.

Hypoxemia/Respiratory Insufficiency could indicate a diagnosis of Acute Respiratory Failure or Acute post Operative Respiratory Insufficiency if the indicators are present. (E.g. Use of C-pap or Non re-breather mask, or O2 saturation less than 92%).

Anemia requires specificity of Chronic Anemia, Acute Blood Loss Anemia, Aplastic Anemia, etc.

Renal insufficiency/chronic kidney disease (CKD) requires added specificity for the stage of the CKD, the Creatinine baseline and further specificity as to possible Acute Renal Failure (ARF), and if indicators present (E.g. nephrotoxic medication usage) ARF with Tubular Necrosis.

FTT, Anorexia may indicate Malnutrition. If present, further specify as to whether it is mild, moderate, or severe.

CHF requires specificity of acute or chronic and systolic or diastolic heart failure.

Right/left sided weakness may indicate a diagnosis of hemiplegia or hemiparesis.

Problems with speech post CVA may indicate a diagnosis of Aphasia.

Drug use History requires clarification of use or abuse and if the Drug Use/Abuse is Ongoing.

Abdominal pain requires documentation of an underlying diagnosis. (E.g. Ulcer, Acute Pancreatitis, etc)

Chest pain requires documentation of an underlying diagnosis. (E.g. CAD, Angina, Costochondritis, etc.)

Gangrene-requires further specificity as to “Wet” infectious or “Dry” ischemic Gangrene

Poorly controlled Diabetes needs clarification whether Uncontrolled or Controlled Diabetes Mellitus.

Hypertensive Emergency needs clarification as to Malignant or Accelerated Hypertension.

DVT needs clarification as to Deep Vein Thrombosis or Thrombophelbitis.

I&D needs clarification as to whether this means Irrigation and Drainage, Exisional Debridement or Non Exisional debridement. (If exisional debridement performed then documentation must state if scalpel was used, clear margins obtained, and depth up to and including deepest layer.)

↓↑Na is not a diagnosis. Documentation must be obtained as to possible Hyper/ Hyponatremia.

Editor's note: Hoffman, at the time of this article's original release, was a CDI specialist in Tampa, Florida. She had been a nurse for more than 20 years and enjoyed writing, painting, and traveling.