Clinical Documentation Query - Michigan Center for Rural ...



Clinical Documentation QueryPt Name:MR #:Acct #:Payor:Unit/Bed:Adm Date:Reviewer: Alyson Swinehart Ext. 20331Query Date: 4/6/2017 11:11:00 AMProvider Comments/Addendum:Mental Status ChangeBy submitting this query, we are merely seeking further clarification of documentation to accurately reflect all conditions that you are monitoring, evaluating, treating or that extend the hospitalization or utilize additional resources of care. Dear Provider,The patient’s Clinical Indicators include:Haldol 10mg IVP PRN ordered administered on 4/3 @ 1205, 1400, 2230 & 4/4 @ 0835 and 1130.Safety companion placed at the bedside. 4-pt. restraints initiated on 4/5 @ 0800Pt. admitted for Sepsis 2/2 E.Coli UTI“Altered Mental Status” has been documented in the 4/4 Progress NoteA more specific diagnosis to describe the mental status change is: Acute Encephalopathy (Please specify the origin of this condition in your progress note.)Metabolic Encephalopathy (Please specify the origin of this condition in your progress note.)Toxic Encephalopathy * (Please specify the origin of this condition in your progress note.)Dementia with Behavioral Disturbance Other (Please specify the condition in your progress note)Unable to provide any additional information ***************************Reference Criteria************************Encephalopathy/DeliriumCLINICAL CRITERIA:There is no specific or official textbook definition; encephalopathy can be accurately described as a generalized alteration in all aspects of brain function (communication, memory, speech, orientation, behavior) due to a systemic underlying cause that is usually reversible. It is typically acute (or subacute) in onset and resolves when the underlying cause is corrected. Common causes of encephalopathy include fever, infection, dehydration, electrolyte imbalance, acidosis, organ failure, sepsis, hypoxia, drugs, poisons, or toxins.Most inpatients with an acutely altered mental status actually have “encephalopathy” causing it and should be diagnosed as such since “altered mental status” is a NONSPECIFIC SYMPTOM. Recognition of encephalopathy is crucial for accurate documentation of the severity of illness of hospitalized patients.DELIRIUM vs. ENCEPHALOPATHYMany physicians consider delirium and encephalopathy as essentially the same thing. However, from a coding perspective, delirium is classified as a mental disorder or as a symptom; encephalopathy is recognized as a specific neurologic diagnosis that identifies toxic and metabolic states affecting the brain. ReferencePinson, R.D., & Tang, C.L. (2013) CDI Pocket Guide. (6th ed.) HCPro, Inc.: United States of America. ISBN: 978-0-9827664-2-2FOR CURRENT INPATIENTS, please document the above response in the PROGRESS NOTES and discuss in the Hospital Course narrative. Once documented in progress notes, CDI can add to the problems and diagnoses list.FOR DISCHARGED PATIENTS, please enter a diagnosis from the selections above into the “Comments:” field before clicking on “Sign” or you may dictate the desired diagnosis work type “40- Discharge Summary” and an addendum will be created for your signature approval. ................
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