I have found that a healthy skepticism needs to be applied within the realm of clinical documentation integrity. In fact, I am thinking of hanging “Caveat Emptor” (Latin for “buyer beware”) sign over my desk! Read More »
Too often an abnormality is an incidental finding, or a lab error and the clinical circumstances, do not support a diagnosis based on that number. Acute hypoxemic respiratory failure can be one of these situations.Read More »
Careful use of terminology may help alleviate miscommunication in situations of potential tragedy. Following the recent death of 33-year-old Marlise Muñoz, who was declared brain dead at a Fort Worth hospital, facilities may want to take the opportunity to review their internal guidelines for...Read More »
Q: We recently admitted a 52-year-old man who was waiting for a liver transplant. He has a history of hepatitis C, chronic back pain, and drug and alcohol abuse. He was found unresponsive at home in a pool of vomit. The toxicology screen on admission was positive for benzodiazepine,...Read More »
Nutritional issues are not uncommon in children and may have a significant impact on a child’s health. Poor nutrition can negatively affect growth, immune system function, emotions, and long term cognitive development. Poor nutrition can also increase a...Read More »
Facilities have always faced problems related to documentation for cardiorenal syndrome. One major problem with the diagnosis is that CDI specialists may query for clarification of cardiorenal syndrome, but physicians and the CDI staff may not clearly understand how each side defines the term.Read More »
The AHA published its first issue of Coding Clinic for ICD-10-CM and ICD-10-PCS along with its final edition of Coding Clinic for ICD-9-CM. In this Coding Clinic, The AHA editorial board reiterates (on p. 11), that it has no...Read More »
