Documentation Clarification Request

(Not part of the medical record)

Purpose: to clarify provider documentation whenever there is conflicting, ambiguous, or incomplete information in the medical record regarding any significant reportable condition or procedure.

Reportable conditions: defined by Official Coding Guidelines as affecting patient care by requiring:

  Clinical Evaluation * Extended length of hospital stay

  Therapeutic treatment * Increased nursing care and/or monitoring

  Diagnostic Procedures

Clinically significant conditions: those listed above as well as those conditions that have implications for future health care needs. Use of a qualifier such as possible, probable, unable to rule out is acceptable in the inpatient discharge summary for cases requiring further work-up after discharge.

Chart review indicates needed clarification based on the Official Coding Guidelines.

Cardiogenic Shock

Defined as:
·  a sustained (>30 minutes) episode of systolic blood pressure <90 mm Hg, and/or
·  a cardiac index <2.2 L/min/m2 determined to be secondary to cardiac dysfunction, and/or
·  the requirement for parenteral inotropic or vasopressor agents or mechanical support to maintain blood pressure and cardiac index above these specified levels (e.g., intra aortic balloon pump (IABP), extracorporeal circulation, ventricular assist devices).
·  hemodynamic compromise (with or without extraordinary supportive therapy) must persist for at least 30 minutes.
Exclusions:
·  Transient episodes of hypotension reversed with IV fluid or atropine
Source: Acute Coronary Syndromes Data Standards (JACC 2001 38: 2114 -30)

Check 1 of these 5 response options so we may know where to find your response.

If this is a retro-query post-discharge, send written response & fax form to HI 375-3485.

* Dictated a note/addendum (use Work Type=15) * Documented on a progress note (send w/ this fax)

* No further documentation is indicated * Not a reportable condition * Other diagnosis noted

* Sandy Beatty, CDS
pager 375-2642 / * Cindy Lemmon, CDS
pager 375-6699 / * Cindy Spann, Director of HI
ext. 376-5011