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UNM Documentation Tips (redirected from UNM Documentation Guidelines)

Page history last edited by kzchang@salud.unm.edu 3 months ago

This is a repository of the UNM HIM CDI & Coding Guidelines to help with Documentation:

 

You can find the most recent updated tipsheets at the intranet page: https://hospitals.health.unm.edu/intranet/HIM/cdi.shtml 

 

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:

Malnutrition 1 Rev 10.05.17.pdf

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)

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