(If exisional debridement performed then documentation must state if scalpel was used, clear margins obtained, and depth up to and including deepest layer.) I&D needs clarification as to whether this means Irrigation and Drainage, Exisional Debridement or Non Exisional debridement. Hypertensive Emergency needs clarification as to Malignant or Accelerated Hypertension.ĭVT needs clarification as to Deep Vein Thrombosis or Thrombophelbitis. Poorly controlled Diabetes needs clarification whether Uncontrolled or Controlled Diabetes Mellitus. Gangrene-requires further specificity as to “Wet” infectious or “Dry” ischemic Gangrene Ulcer, Acute Pancreatitis, etc)Ĭhest pain requires documentation of an underlying diagnosis. Problems with speech post CVA may indicate a diagnosis of Aphasia.ĭrug use History requires clarification of use or abuse and if the Drug Use/Abuse is Ongoing.Ībdominal pain requires documentation of an underlying diagnosis. Right/left sided weakness may indicate a diagnosis of hemiplegia or hemiparesis.
If present, further specify as to whether it is mild, moderate, or severe.ĬHF requires specificity of acute or chronic and systolic or diastolic heart failure. nephrotoxic medication usage) ARF with Tubular Necrosis.įTT, Anorexia may indicate Malnutrition. 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. Use of C-pap or Non re-breather mask, or O2 saturation less than 92%).Īnemia requires specificity of Chronic Anemia, Acute Blood Loss Anemia, Aplastic Anemia, etc.
Hypoxemia/Respiratory Insufficiency could indicate a diagnosis of Acute Respiratory Failure or Acute post Operative Respiratory Insufficiency if the indicators are present. Urosepsis could be UTI or Sepsis secondary to UTI. If with associated Infection, metabolic condition, etc. 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.ĪMS needs clarification as to possible Acute Confusional State, Alzheimer’s Dementia, or Alzheimer’s with Behavioral Disturbance. Many novice CDI specialists do not readily identify when a diagnosis needs clarification.
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