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Expected Mortality

CHF, COPD & Afib WOB, Sats, RR BiPAP ABG results Thin, sunken temples BP, gtt’s started Expected Mortality Rate: 1.7%. CHF, COPD & Afib ADD: Respiratory Failure Acidosis Decubitus ulcer Malnutrition Cardiogenic Shock Expected Mortality Rate: 36.3%. Expected Mortality. PNA

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Expected Mortality

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  1. CHF, COPD & Afib WOB, Sats, RR BiPAP ABG results Thin, sunken temples BP, gtt’s started Expected Mortality Rate: 1.7% CHF, COPD & Afib ADD: Respiratory Failure Acidosis Decubitus ulcer Malnutrition Cardiogenic Shock Expected Mortality Rate:36.3% Expected Mortality

  2. PNA Acute COPD Mortality Rate:0.3% Expected Mortality • PNA • Acute COPD • Add: • Malnutrition • Decubitis Ulcer • Mortality Rate:2.3% • PNA • Acute COPD • MODIFY: • Malnutrition, SEVERE • Decubitis Ulcer, STAGE IV • Mortality Rate: 9.2%

  3. HCAPtranslates / codes to Simple pneumonia • Consider: PNA, possibly due to: • gram negative organism • Specific suspected organism

  4. The Extra Step: • Include ALL chronic conditions • present and stable but managed

  5. Cancer • Primary vs Secondary • Specify ALL metastatic sites • Active … Remission … Resolved • Include all associated diagnoses

  6. Urosepsistranslates / codes to Simple UTI • Consider: Sepsis from a UTI

  7. The Extra Step: • For each medication • Associated diagnosis • For each ordered study • Suspected diagnosis

  8. When is a PE resolved?? • If PE is felt still present & being treated: • Identify as acute or subacute • Even if from a recent admission

  9. ACUTE CHFtranslates / codes to CHF, not further specified • Consider: Specify diastolic &/or systolic Will then capture ACUTE

  10. The Extra Step: • For each abnormal finding • (Lab, radiology, exam) • Describe clinical significance • INCLUDE suspected cause • NAME IT

  11. ESRD • With fluid overload or pulmonary edema • Is it NON-CARDIOGENIC? • Or is it CHF • What is the cause (non-compliance?)

  12. END STAGE COPD with continuous home O2 translates / codes to COPD only • Consider: • COPD, Acute Exacerbation • Acute & Chronic Respiratory Failure

  13. The Extra Step: • Specify supportive facts for diagnosis • Quantify Risk Stratification

  14. History of…?? • Is the condition truly resolved?Or is it chronic & stable with ongoing management

  15. “Post-operative” Frequently translates / codes to complication • Caution on intended meaning: • TemporalvsCausativerelationship • Clarify if INTEGRAL to procedureor EXPECTED part of recovery period

  16. The Extra Step: • Include ALL diagnosis being considered, worked up or treated • “possible”, “probable”, “likely” • Update diagnosis status • Ruled in or out • Remains possible

  17. Altered Mental Status: Is it? • Acute Confusion • Chronic dementia…or acutely worse? • Acute delirium • Encephalopathy • Include specific suspected causes

  18. Symptoms (dyspnea, chest pain, dizziness, weakness, fever) translates / codes to ???? • Explicitly state suspected cause • d/t arrythmia, COPD, CHF, PNA, etc. • d/t unstable angina or CAD, pleurisy, GERD, chest wall pain • d/t hypotension / dehydration • likely source, or bacterial infection unknown source

  19. The Extra Step: • Relate conditions & State connections • UTI due to Foley • specific conditions due to prior CVA • Manifestations & Sequela

  20. Manifestations of disease WITHOUTExplicit linkage translates / codes to Uncomplicated DM, HTN • Consider – use adjective or “due to” • Diabetic nephropathy or Hypertensive CHF

  21. The Extra Step: • Carry diagnoses throughout stay • Include ALL diagnoses at discharge • Acute • Chronic • Resolved during stay

  22. Condition with “VS” (differential diagnoses) translates / codes to Condition ONLY • Consider: • Identify primary suspected cause (then follow with alternatives) • Clearly indicate RULED IN & OUT diagnoses

  23. Use STRONG terms: • Failure • Shock • Coma • Encephalopathy

  24. The Extra Step: • Renal Status • CKD Stage? • Acute Renal Failure due to …

  25. Use STRONG Qualification & Links: • Acute, Acute on Chronic • Sub-acute, Chronic • Congenital • Exacerbated • Uncontrolled • Mild, Moderate, Severe • Due to, Secondary to • Unstable

  26. The Extra Step: • Abbreviations • Always spell it out the first & last time • Different areas expertise & knowledge • Prevent confusion & errors

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