** This page is not up to date **
This is a repository of the UNM HIM CDI & Coding Guidelines to help with documentation:
You can find the most recent updated tip sheets on the UNMH Clinical Documentation Integrity intranet page: https://hospitals.health.unm.edu/clinical-documentation/
These are also within the Moodle practice management modules in the Inpatient Diagnosis and Specificity > Documentation Tips module resources.
General Best Practice words summary card: Best Practice Documentation Examples.docx
Here are the available common ones:
Adults:
Substance Use Page 1_2 TipSheet Update Jan 2020.docx
Alcohol Disorder Tip Card-combined.docx
Congestive Heart Failure_.pdf
Tip Sheet Hospital Medicine.docx
Pediatrics:
UNMH Guideline Pediatric Encephalopathy_Final.doc
UNMH Guideline Pediatric Shock_FINAL.doc
UNMH Guideline Pediatric SIRS Sepsis_Final.doc
Malnutrition, Pediatric CDI and Coding Guideline.pdf
Respiratory Failure (Pediatric) Guideline_final.doc
Tip Sheet Pediatrics.docx
L&D Top Ten Queries:
Top Ten workstation tip sheet
COMMON QUERIES:
Acute Respiratory Failure
Diagnostic criteria: Hypoxemic, Hypercapnic, or both - with signs of respiratory difficulty on exam
- Acute hypoxemic
- pO2 <60mmHg on RA per ABG, or
- SpO2 <91% on RA per pulse oximetry, or
- P/F ratio <300 on O2 - with new O2 need (not chronic supplemental oxygen-dependent)
- Acute on chronic hypoxemic
- worse dyspnea w/increased O2 need, or
- worse hypoxemia: decrease in baseline pO2 by >10mmHg or SpO2 <91% on usual home O2
- Example: home O2 at 2 L/min and baseline SpO2 >91%, but pt with dyspnea and requiring 4 L/min to keep SpO2 >91%
- Acute hypercapnic (acute retention, impaired ventilation)
- pCo2 > 50mmHg with pH <7.35
- Acute on chronic hypercapnic
- pCO2 > 50mmHg with pH <7.35, or
- increase in baseline pCO2 by ≥10mmHg on ABG
Tip: COPD patients without home O2 need because baseline SpO2 >91% are not in chronic respiratory failure.
Examples of word specifiers:
- "acute hypercapnic respiratory failure with respiratory acidosis" (not just "pt has respiratory acidosis")
- "acute hypoxemic respiratory failure as evidenced by P/F ratio <300 on 3L/min supplemental oxygen" or pO2 <60mmHg on room air...
- "acute exacerbation of chronic hypoxemic respiratory failure requiring a increase in supplemental oxygen above baseline..."
"Respiratory insufficiency" describes a symptom and some sort of hypoxia, but probably in the pO2 60-79.9mmHg or SpO2 91-95% range.
- If patient meets diagnostic criteria for respiratory failure, you may be queried to specify.
|
Acute Respiratory Failure in Pediatrics (29 days -18 yrs); (neonates ≤28 days/old)
Diagnostic criteria: similar numbers to adults, but at UNMH consensus guideline is that neonate respiratory failure is defined by SaO2 ≤87% or requiring more than 3 LPM NC or requires High Flow Oxygen.
- Hypoxemic respiratory failure
- pO2 < 60 mmHg on room air, or
- P/F ratio <300 on supplemental oxygen, or
- 10-15 mmHg decrease in pO2 from baseline (if known)
- Hypercapnic respiratory failure
- pCO2 > 50 mmHg with pH <7.35, or
- VBG in lieu of ABG
- End-tidal CO2 level >45 mmHg on capnography
- 10-15 mmHg increase in baseline pCO2 (if known)
Word specifics:
- In babies ≤28 days old, "respiratory insufficiency" = respiratory failure.
- In pediatric hospitalized patients, if SpO2 >87% on RA or not requiring more than 3 LPM NC, you can use "acute respiratory distress" to indicate higher severity of illness.
- Different than adults where we try not to use "acute respiratory distress" or "acute respiratory insufficiency."
Tip: Check in these babies whether they require High Flow Oxygen before using either term (respiratory insufficiency or failure).
Documentation guideline from Pediatrics team attached.
|
(SEE the LINKS ABOVE for the UNM PEDS RESP FAILURE GUIDELINES)
Comments (0)
You don't have permission to comment on this page.